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DELLQUEST'S 

RARE  BOOK  SHOP 


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3JL  iL<^ 


OR  HINTS  ON  THE  EMERGENCIES  OF 


FIELD  CAMP  AND  HOSPITAL  PRACTICE, 


BY  S.  D.  GROSS,  M.  D., 

Professor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia. 


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AUGUSTA,     GA.: 
Steam  Power  Press  Ohronicle  &  Sentinel 

1861. 


14* 


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The  sole  object  which  prompts  the  publication  of  this  work,  is  the 
desire  to  place  it  within  the  reach  of  young  physicians,  many  of  whom 
have  entered  our  volunteer  service,  perhaps  not  always  with  a  full 
knowledge  of  the  weighty  responsibility  of  their  position.  It  treats, 
very  succinctly,  of  various  matters  not  generally  discussed,  except  in 
large  and  ponderous  volumes,  inaccessible  in  the  camp  and  on  the  battle 
field.  It  is  essentially  a  book  for  emergencies  ;  portable,  easy  of  re  fcr- 
cnce,  always  at  hand. 


'^. 


THE  FLOWrRS  COLLECTION  ^,>  ^-'^f^f^ 

MILITARY  SURGERY. 


CHAPTER  I. 

nrSTORICAI,   SKETCH    OF    MILITARY   SURGERY. 

The  duties  and  requirements  of  military  are  essentially 
similar  to  those  of  civil  snrccery.  It  is  founded  upon  the 
same  knowledge  of  anatomy,  medicine,  and  the  associate 
sciences ;  it  demands  the  same  qualifications,  physical, 
moral,  and  intellectual.  The  difterence  consists  in  the 
application  of  our  knowledge  rather  than  in  its  range  or 
depth.  The  civil  surgeon  remains  at  home  ;  the  military 
follows  the  army,  examines  recruits  for  the  public  service, 
and  superintends  the  health  of  the  troops.  If  the  former 
is  well  educated,  he  will  be  quite  as  competent,  at  any 
time,  as  the  latter  to  perform  these  duties  ;  for  the  emer- 
gencies of  civil  are  often  not  less  trying  than  those  of  mili- 
tary practice,  although  they  may  not  be  on  so  large  a  scale. 

The  best  civil  have  often  also  been  the  best  military  sur- 
geons. In  proof  of  this  assertion  it  is  necessary  only  to 
refer  to  the  names  of  Pare,  Wiseman,  Schmucker,  Kern, 
Larrey,  Guthrie,  Charles  Bell,  Alcock,  Thomson,  Ballin- 
gall,  and  Macleod,  of  Europe ;  or  to  those  of  Rush,  Jones, 
Thacher,  Mann,  and  Horner  of  our  own  country. 

Military  surgery  occupies,  at  the  present  day,  a  deserved- 
ly high  rank  in  tlic  estimation  both  of  the  profession  and 
of  the  public.  The  war  in  the  Crimea,  the  mutiny  in 
India,  and  the  recent  convulsions  in  Italy,  all  attended  with 
so  much  waste  of  blood  and  life,  have  attracted  to  it  the  uni- 
versal attention  of  the  profession  ;  and  the  revolutionary 
movements  now  in  progress  in  our  own  country  invest  it 
with  a  new  and  fearful  interest  to  everj-  American  physi- 
cian. Its  praises  have  been  sung  by  Homer,  and,  in  all 
ages  of  the  world,  governments  have  extended  to  it  a  fos- 
tering hand.  As  a  distinct  branch,  however,  of  the  heal- 
ing art,  it  dates  back  no  further  than  the  early  part  of  the 
sixteenth  century,  when  it  was  inaugurated  by  Ambrose 
Pare,    by   the   publication   of  his  treatise   on    "Gunshot 


"?  :b  3  S  o  7 


C  •    •  v»         MiUtari)  Stirr/erj/, 

WoniuJ.s"  tlie  fruits  of  his  observations  in  tlie  French  army 
in  Italy.  This  man,  wiio  was  surgeon  to  four  snecessive 
kings,  was  an  eyc-witncss  of  the  numerous  French  cam- 
paigns, from  'iij'SQ,  down  to  the  battle  of  Moncontour,  in 
loG'J,  a  period  of  thirty-three  years.  His  popularity,  both 
as  a  civil  and  military  surgeon,  was,  up  to  that  time,  witli- 
out  a  [tarallel.  Tlie  soldiers  worshiped  him  ;  and  the  suc- 
cess of  more  than  one  siege,  as  well  as  of  one  battle,  was  due 
almost  exclusively  to  the  wonderful  influence  of  his  pres- 
ence. His  treatise  on  "  Gunshot  Wounds"  ai)peare(i  to- 
wards the  middle  of  tlie  sixteenth  century,  a-id,  ai'ter  hav- 
ing passed  through  various  editions,  was  ultimately  incor- 
porated in  his  surgical  writings,  published  nearly  a  quarter 
of  a  century  later. 

In  England,  the  earliest  work  on  military  surgery  was 
that  of  Thomas  Gale,  entitled  a  ''•  Treatise  on  Gunshot 
"Wounds,"  designed  chiefly  to  confute  tlic  errors  of  some 
of  his  contemporaries,  respecting  the  supposed  poisonous 
nature  of  thcs«  lesions.  Gale  was  born  in  1507,  and  after 
having  served  in  the  army  of  King  Henry  VIII.,  at  Mon- 
trieul,^  and  also  in  that  of  King  Philip,  al  St.  Quintin, 
linally  settled  at  London,  where  he  acquired  great  distinc- 
tion in  his  profession.  In  lGo9  appeared  the  work  of  J. 
"Woodal!,  ''The  Suigeon's  Mate;  or,  Military  and  Domestic 
Gnrgery."  He  was  surgeon  under  Queen  Elizabeth,  by 
whom  he  was  sent  to  France,  along  with  the  troops  that 
were  dispatched  to  the  assistance *of  Henry  IV.  and  Lord 
"Willoughbv.  In  107U,  Eichard  Wiseman,  sergeant-surgeon 
to  King  Charles  IL,  published  his  famous  "Chirurgical 
'J'reatises,"  one  of  wiiicb  was  expressly  devoted  to  the  con- 
sitlij''ati<jn  of  gunshot  wounds.  Two  years  after  this  a 
treritiso  on  gunshot  wounds  was  published  at  London,  by 
John  Brown,  also  surgeon  to  Charles.  He  was  a  man  of 
eminence,iui;d  served  with  much  credit  in  the  Dutch  war 
of  1 60.3.  The  next  English  work  on  military  surgery  ap- 
peared in  1714,  from  the  pen  of  John  Ranby,  sergeant- 
surgeon  to  George  IL,  under. the  title  of  "The  Method  of 
Treatinir  Gunshot  Wounds."  After  Ranby  came  the  im- 
])erish;d)le  work  of  John  Hunter,  familiar  to  every. reader 
of  English  surgical  literature.  The  part  relating  to-  gun- 
shot wouuils  was  founded  upon- his  observations  made 
while  serving  as  staff-surgeon  at  Belleisle  and  in  Portugal, 
and  is  one  ()f  the  most  precious  legacies  of  the  last  ceu- 
tiu'y,  near  the  close  of  which  it  appeared. 


Military  Surgery. 

The  present  century  has  supplied  quite  a  number  of 
works  on  military  surgery,  as  is  shown  by  the  valuable 
publications  of  Larrey,  Hennen,  Hecker,  Augustin,  Guth- 
rie, Thomson,  Hutchinson,  Ballingall,  Baudens,  and  others, 
which  have  contributed  so  much  to  the  elevation  of  this 
department  of  the  healing  art.  Some  of  these  works  have 
been  re-issued  in  this  country,  and  have  acquired  a  wide 
celebrity. 

We  must  not  forget,  in  this  rapid  enumeration  of  works 
on  military  surgery,  the  "•Manuel  de  Chirurgien  d'Armee" 
of  Baron  Percy,  published  at  the  commencement  of  the 
revolutionary  war  in  France.  It  is  a  model  of  what  such 
a  treatise  ought  to  be. 

The  only  work  on  this  department  of  science  yet  fur- 
nished in  this  country,  is  that  of  the  late  Dr.  James  Mann, 
published  at  Dedham,  Massachusetts,  in  181d.  It  is  enti- 
tled "Medical  Sketches  of  the  Campaigns  of  1812,  '18,  and 
'14,"  and  forms  a  closely-printed  volume  of  upwards  of 
three  hundred  octavo  pages. 

The  latest  treatise  on  this  subject  in  the  English  language 
is  that  of  Dr.  George  II.  B.  Macleod,  now  Professor  of 
Surgery  at  Glasgow,  entitled  "  I^otes  on  the  Surgery  of  the 
War  in  tbe  Crimea  ;  with  remarks  on  the  Treatment  of 
Gunshot  Wounds."  It  is  a  work  of  intense  interest,  writ- 
ten with  great  ability  by  an  accurate  and  diligent  observer, 
and  is  worthy  of  a  place  in  every  medical  library.  To  this 
work  frequent  reference  will  be  made  in  the  following  pages. 

To  Dr.  Lewis  Stromeyer,  Physician  of  the  Royal  Han- 
overian Arm}',  we  are  indebted  for  the  most  recent  German 
work  on  militar}'  surgery.  It  was  issued  in  1858,  under 
the  title  of  "Maximen  der  Kriegslieilkunst,"  in  two  duo-, 
decimo  volumes,  to  which  a  Supplement  was  added  in  the 
early  part  of  the  present  year.  A  more  valuable  contribu- 
tion to  this  department  of  surgery  could  hardly  be  im- 
agined. 

Besides  the  above  more  recent  works,  the  reader  should 
carefully  study  the  "Principles  of  Military  Surgery,"  by 
the  late  Dr.  John  Hennen,  one  of  the  most  zealous  and 
distinguished  military  surgeons  that  Great  Britain  has  yet 
produced  ;  a  man  of  vast  experience  and  of  the  most  en- 
lightened views  upon  everything  he  has  touched  with  his 
pen. 

Perhaps  the  most  systematic  work  on  the  subject  in  the 
English  language  is  that  of  Sir  George  Ballingall,  entitled 


'3  3  3  S:o7 


MilUar)f  Surgery. 

"Outlines  of  Military  Surpfery,"  the  last  edition  of  which, 
the  tonrtli,  appeared  only  recently  at  EJinbnrcrh,  where  the 
author  held  tor  m my  ye:ir3  the  chair  of  military  siirijcry, 
for  a  I0112J  timo,  wc  believe,  the  only  one  in  Great  Britain. 
It  is  a  jirodnction  of  ninch  merit,  and  is  destined  to  main- 
tain a  very  high  rank  in  this  species  of  literature. 

The  works  of  the  late  Mr.  (jeorjjrc  Guthrie  also  deserve 
attentive  study  :  they  are  written  with  «;reat  clearness  and 
ability,  and  embody  the  results  of  an  immense  experience, 
acquired  during  many  years  of  ardu  )us  and  laithful  labor 
and  observation  in  tlie  British  ar.ny.  I  have  alw.iys  re- 
garded the  works  of  this  great  man  as  among  the  most 
valuable  contributions,  not  only  to  military  surgery,  but  to 
surgery  in  general,  in  the  English  language. 

With  these  works  before  him,  the  student  of  military 
surgery  cannot  fail  to  make  himself  in  a  short  time  per- 
fectly familiar  with  everything  pertaining  to  the  subjects  of 
which  they  treat.  He  should  also  provide  himself  with  a 
copy  of  the  excellent  little  volume  entitled  "Hints  on  the 
Medical  Examination  of  Recruits  for  the  Army,"  by  the  late 
Br.  Thomas  Henderson,  formerly  Professor  of  Medicine  in 
Columbia  College,  Washington  City.  A  new  edition  of  it 
was  published  a  few  years  ago  by  Dr.  Richard  H.  Coolidge, 
of  the  United  States  army. 

Although  we  have  long  had  one  of  the  most  respectable 
and  thoroughly  organized  army  and  navy  medical  stafts  in 
the  world,  our  country  has,  nevertheless,  not  produced  one 
great  military  surgeon  ;  simply,  it  may  be  presumed,  be- 
cause no  opportunity  has  occurred  since  the  establishment 
of  our  government  in  which  the  men  in  the  public  service 
could  distinguish  themselves.  Their  aid  has  been  required 
in  the  duello  and  in  skirmishes  rather  than  in  great  battles, 
such  as  have  so  often  characterized  the  movements  of  the 
armies  of  the  Old  World.  We  make  no  exception  in  this 
remark  in  favor  even  of  the  battles  that  were  fought  during 
the  Revolution,  and  during  our  Late  War,  as  it  has  usually 
been  designated,  with  Great  Britain.  Those  engagements 
were,  for  the  most  part,  comparatively  bloodless.  Happily 
living  under  a  flag  which,  until  recently,  commanded  alike 
the  respect  and  the  admiration  of  all  nations,  belonging  to 
a  government  which  was  at  peace  with  all  foreign  powers, 
the  medical  and  surgical  staffs  of  the  public  service  had 
Httle  else  to  do  than  to  prescribe  for  such  diseases  as  arc 
incident   to   civil  practieo.     America  has  never  witnessed, 


Military  Surgery.  0 

and  we  trust  in  God  she  never  may  witness,  such  carnage 
as  that  which  attended  the  footsteps  of  Napoleon  at  the 
bridge  of  Lodi,  at  Leipzig,  at  Dresden,  and  at  Waterloo  ; 
or  which,  more  recentl}-,  characterized  the  exploits  of  the 
English,  French,  and  Russian  forces  in  the  Crimea;  or  of 
the  French,  Italian,  and  Austrian  armies  in  Italy;  or  of  the 
Etiglish  soldiers  during  Ihe  late  rebellion  in  India.  Nor 
has  she  ever  been  engaged  in  one  great  naval  battle  similar 
to  that  of  La  liogue,  Toulon,  Trafalgar,  or  Aboukir.  A 
number  of  highly  respectable  physicians  accompanied  our 
army  to  Mexico,  but  the}^  returned  without  any  special 
laurels,  and  without  any  substantial  contributions  to  mili- 
tary medicine  and  surgery. 


CHAPTER  II. 

IMPOKTAMCE   OP    MILITARY   SURGERY. 

It  is  impossible  for  any  civilized  nation  to  place  too  high 
an  estimate  upon  this  branch  of  the  public  service.  With- 
out the  aid  of  a  properly  organized  medical  staff,  no  army, 
however  well  disciplined,  could  successfully  carry  on  any 
war,  even  when  it  is  one,  as  that  which  is  now  impending 
over  us,  of  a  civil  character.  No  men  of  any  sober  reflection 
would  enlist  in  the  service  of  their  country,  if  they  were 
not  positivel}'  certain  that  competent  physicians  and  sur- 
geons would  accompany  them  in  their  marches  and  on  the 
lield  of  battle,  ready  to  attend  to  their  diseases  and  acci- 
dents. Hence  military  surgery,  or,  more  correctly  speak- 
ing, military  medicine  and  surgery,  has  alwayt  occupied  a 
deservedly  high  rank  in  public  estimation. 

Dionis,  a  surgeon  far  in  advance  of  his  age,  in  referring 
to  the  value  of  medical  services  to  soldiers,  exclaims,  with 
a  burst  of  eloquence  :  "We  must  then  allow  the  necessity 
of  chirurgery,  which  daily  raises  many  persons  irom  the 
brink  of  the  grave.  How  many  men  has  it  cured  in  the 
army  !  How  many  great  conmianders  would  have  died  of 
their  ghastly  wounds  without  its  assistance  !  Chirurgery 
triumphs  in  armies  and  in  sieges.  'Tis  true  that  its  emjtirc 
is  owned  :  'tis  there  that  its  etfects,  and  not  words,  express 
its  euloguim." 

The  contidenee  reposed  by  soldiers  in  the  skill  and  hu- 
manity of  their  surgeon  has  often  been  of  signal  service  in 


10  Military  tSurgert/. 

supporting  them,  when  exhausted  by  hunger  and  fatigue, 
in  their  strugles  to  repel  ilie  advancing  foe,  or  in  success- 
fully maintaining  a  siege  when  the  prospect  of  speedy  sur- 
render was  at  hand.  Who  that  is  versed  in  the  history  of 
our  art  does  not  remember  with  what  enthusiasm  and  re- 
solve Ambrose  Pare,  the  father  of  French  surgery,  in- 
spired the  souls  of  the  half-starved  and  desjtonding  garri- 
son at  Metz,  in  1552,  when  besieged  by  100,000  men  under 
the  personal  command  of  Charles  V.  ?  Sent  thither  by  his 
sovereign,  he  was  introduced  into  the  city  during  the  niglit 
by  an  Italian  captain  ;  and  the  next  morning,  when  "he 
showed  himself  upon  the  breach,  he  was  received  with 
shouts  of  welcome.  "We  shall  not  die,"  the  soldiers, 
exclaimed,  "even  though  wounded  ;  Pare  is  among  us." 
The  defense  from  this  time  was  conducted  with  renewed 
vigor,  and  the  French  army  ultimately  com})letely  triumph- 
ed, through  tlie  sole  influence  of  this  illustrious  surgeon. 

l:so  man  in  the  French  army  under  Xapolcon  rendered 
so  many  and  such  important  services  to  the  French  nation 
as  Larrey,  the  illustrious  surgeon  who  accompanied  that 
mighty  warrior  in  his  various  campaigns,  everywhere  ani- 
mating the  troops  and  doing  all  in  his  power  to  save  them 
from  the  destructive  effects  of  disease  and  injury.  His 
humanity  and  tenderness  was  sublime  ;  and  so  highly  was 
liis  conduct,  as  an  honest,  brave,  and  skill! ul  surgeon,  ap- 
preciated l)y  Kapoleon,  that  he  bequeathed  hinr  a  large 
sum,  with  the  remark  that  "Larrey  was  the  most  virtuous 
man  he  had  ever  known." 


CHAPTER  m. 

QUALIFICATIONS  AND  DUTIES  OP   MILITARY  SURGEONS. 

It  is  of  paramount  importance  that  none  but  men  of  the 
best  talent  and  of  the  highest  education  should  be  received 
into  the  public  service.  Rigid  as  the  examination  of  the 
army  and  navy  medical  boards  already  are,  there  is  need  of 
increased  rigor,  in  order  that  none  may  be  admitted  who 
are  not  thoroughly  prepared  for  the  discharge  of  their  re- 
sponsible duties.  Equal  vigilance  should  be  exercised  in 
regard  to  the  introduction  of  physicians  and  surgeons  into 
the  volunteer  service.  Every  regiment  should  be  provided 
with  an  able  medical  head,  a   man  ready  for  every  emer- 


Militarif  Surgery.  11 

gency,  howener  tryinsf  or  unexpected  ;  a  man  skilled  in  the 
diagnosis  and  treatment  of  diseases,  and  competent  to  per- 
form any  operation,  whether  small  or  large,  on  the  spur  of 
the  moment.  To  do  this,  he  nuist  be  more  than  a  mere 
physician;  he  must  be  both  a  physician  and  surgeon,  in  the 
true  sense  of  the  terms,  otherwise  he  will  be  uniit,  totally 
unfit,  for  his  position.  He  must  have  been  educated  in  the 
modern  schools;  be  of  un(loui)te<l  courage,  pn)inpt  to  act, 
willing  to  assume  responsibility,  humane  and  sym[)atliizing, 
urbane  and  courteous  in  his  manners  ;  in  short,  a  medical 
gentleman,  as  well  as  a  medical  philosopher,  not  hesitating, 
if  need  be,  to  perform  the  most  menial  services,  and  to  do 
all  he  can  to  preserve  the  health  and  the  lives  of  tlie  sol- 
diers committed  to  his  care.  The  white-gloved  gentry, 
such  as  figured  in  some  of  the  regiments  that  went  to 
Mexico,  have  no  business  in  the  service;  their  time  can  be 
much  better  spent  in  the  discharge  of  their  domestic  duties, 
in  the  practice  of  their  neighborhood,  and  in  the  contem- 
plation, at  a  distance,  of  the  miseries  of  war. 

It  is  much  to  be  feared  that,  from  the  rapid  manner  in 
which  our  volunteers  have  been  hurried  together,  many 
medical  men.  old  as  well  as  young,  have  already  been  ad- 
mitted into  the  service  utterl}'^  unfit  for  the  ofHce.  If  this 
be  the  case,  let  our  authorities,  warned  by  the  past,  be 
more  circumspect  in  regard  to  the  future.  Above  all,  let 
them  sec  that  the  medical  staffs  of  the  brave  volunteers  of 
the  country  be  not  defiled  b}^  charlatans  and  unworthy  men. 
between  whom  and  the  regular  practitioners  there  cannot 
possibly  be  any  professional,  much  less  social  intercourse, 
either  in  civil  or  military  practice.  The  medical  men 
should  be  on  the  best  possible  terms  with  each  other;  all 
causes  of  discord  and  bickering  among  themselves  should 
be  studiously  obviated,  and  speedily  suppressed,  if,  'infor- 
tunately,  they  should  arise.  Concert  of  action  on  the  part 
of  the  medical  corps  is  indispensable  to  the  success  of  the 
medical  operations  of  an  army. 

Ev(4i-y  regimental  surgeon  should  have  at  least  two  assis- 
tants in  tiuie  of  peace,  or  during  the  inactivity  of  the  troops 
under  his  charge  ;  when  on  active  duty,  on  the  c(mtrary, 
the  number  should  at  least  be  double,  especially  in  the  face 
of  an  anticipated  bloody  engagement.  These  assistants 
should  be  selected  solely  with  "reference  to  their  compe- 
tency; they  should,  like  the  princijial,  be  eminently  intel- 
ligent, and  ready,  in  case  of  emergency,  to  perform  uu-y 


12  Military  iSurgery. 

operation  that  occasion  may  demand.  Every  brigade  should 
have  its  brigade  surgeon,  who  shoukl  exercise  a  supervisory 
control  over  the  regimental  surgeons,  principals  as  well  as 
assistants,  as  every  tState  should  have  its  surgeon-general, 
or  medical-director,  whose  duty  it  should  bo  to  superintend 
the  whole  medical  arrangements,  seeing  that  the  candidates 
for  the  medical  department  of"  the  service  be  subjected  to 
a  rigid  examination,  attending  to  the  purchase  of  medicines 
and  instruments,  providing  suitable  nurses,  inspecting  the 
quarters,  stores,  and  pro\i3ions,  that  nothing  of  an  un- 
wholesome character  may  find  its  way  into  the  ranks,  point- 
ing out  the  proper  location  of  camps,  and  the  construction  of 
hospitals,  and  giving  general  instructions  in  regard  to  mili- 
tary hygiene,  or  the  best  means  of  avoiding  disease  and 
accident. 

Prior  to  every  engagement  at  all  likely  to  be  severe  or 
Kerious,  a  proper  number  of  men  should  be  detailed  for  the 
purpose  of  rendering  prompt  assistance  to  the  wounded, 
and  carrying  them  off  the  field  of  battle  to  the  hospitals, 
or  tents,  erected  for  their  accommodation  and  treatment. 
Unless  this  be  done  as  a  preliminary  step,  much  sufiering 
will  inevitably  be  the  consequence,  if  not  great  confusion, 
highly  prejudicial  to  the  issue  of  the  combat.  So  fully 
aware  are  the  leaders  and  sub-commanders  of  our  armies 
of  this  fact  that  they  never  permit  any  man  to  fall  out  of 
the  ranks,  during  an  engagement,  to  perform  this  service. 

While  the  battle  is  progressing  it  is  the  dut}'  of  the  sur- 
geon and  of  his  assistants  to  remain  in  the  rear  of  the  com- 
batants, as  much  as  possible  out  of  harm's  way,  but  at  the 
same  time  ready  and  on  the  watch  to  render  the  promptest 
possible  aid.  They  must  be  Argus-eyed,  and  in  the  full 
possession  of  their  wits.  One  of  the  leading  difierences 
between  military  and  civil  practice  is  the  instantaneous  ac- 
tion so  often  demanded  by  the  one  and  the  delay  so  fre- 
quently admitted  by  the  other. 

The  first  duty  of  every  surgeon  is  to  the  olticersand  men 
of  his  own  corps;  but  on  the  field  of  battle,  or  socwi  after 
the  battle  is  over,  he  is  often  brought  in  contact  with  the 
members  of  other  regiments,  or  even  with  the  wounded  of 
the  enemy  ;  and  under  such  circumstances  the  dictates  of 
humanity,  not  less  than  the  usages  of  war,  demand  that  he 
should  render  his  services  wherever  they  ma}^  be  likely  to 
be  useful.  The  medical  oiHcers  of  the  contending  parties 
sometimes  meet  upon  such  occasions,  and,  when  this  is  the 


31ilUari/  iSurgeiy.  10 

case,  their  conduct  should  invariably  be  characterized  by 
the  courtesy  of  tlie  gentleman,  not  the  asperity  of  the 
enemy.  They  should  not  forget  that  they  are  brethren  of 
the  same  noble  profession,  acting  in  the  capacity  of  minis- 
termg  angels  to  the  sick  and  dying.  Country  and  cause 
alike  should  be  forgotten  in  generous  deeds. 

By  the  usages  of  war  in  atl  civilized  countries,  the  sur- 
geons are  always  respected  by  the  enemy  if,  during  an  en- 
gagement, they  happen  to  fall  accidentally  into  their  hands. 
Their  lives  are  regarded  as  sacred,  the  more  so,  as  they  are 
comparatively  defenseless.  They  are  not,  however,  during 
the  rage  and  smoke  of  the  battle-field,  always  easily  distin- 
guishable from  the  other  ofHcers,  or  even  the  common  sol- 
diers. The  green  sash,  their  distinctive  badges  of  office, 
does  not  alwa3-s  afford  them  immunity,  because  it  is  not 
always  recognized ;  and  it  is  worthy  of  consideration 
whether,  as  an  additional  safeguard,  the  word  "surgeon" 
should  not  be  embroidered  in  legible  characters  upon  a 
piece  of  cloth,  to  be  thrown  across  the  chest  in  time  of 
battle.  The  signilicauce  of  such  a  badge  could  not  be  mis- 
taken by  friend  or  foe,  and  would  bo  the  means  of  saving 
mauv  valuable  lives. 


CILIPTER  IV. 

.MEDICAL  i;(iUIPiIENTS,  STORES  AND  HOSPITALS. 

Every  regiment,  or  body  of  military  men,  should  be  am- 
ply provided,  in  time  of  war,  with  the  means  of  conveying 
the  wounded  and  disabled  from  the  field  of  battle.  For 
this  purpose  suitable  carriages  and  litters  should  constantly 
be  in  readiness.  The  carriages  should  be  built  in  the  form 
of  light  wagons,  drawn  each  by  two  horses ;  with  low 
wheels,  easy  springs,  and  a  large  wide  body,  furnished  with 
a  soft  mattress  and  pillows,  and  capable  of  accommodating 
not  less  than  eight  or  ten  persons,  while  arrangements 
might  be  made  at  the  side  for  seating  a  number  more,  as 
in  the  French  voiturc.  As  a  means  of  protection  against 
the  sun  and.  the  rain,  it  should  have  a  light  cover  of  oil- 
cloth or  canvass. 

A  great  number  of  lifters,  or  bearers,  v.-ill  be  found  de- 
scribed in  treatises  on  military  surgery ;  but  I  am  not  ac- 
quainted with  any  which  combine  so  much  eimplicity  and 


14  Military  Surgeri/. 

cheapness,  with  lightness  and  convenience,  as  one  which, 
after  a  good  deal  of  reflection,  I  liave  just  devised.  It  con- 
sist of  \wo  equal  parts,  conducted  at  the  ends  hv  stout 
hinges,  the  arrangement  being  such  as  to  permit  of  their 
being  folded  for  the  more  easy  transportation  on  the  field 
of  battle.  Each  part  has  a  side  piece  of  wood,  three  leet 
four  inches  long,  by  two  inches  in  depth,  and  an  inch  and 
a  half  in  thickness,  the  free  extremity  terminating  in  a 
slightly  curved  handle.  The  side  pieces  are  united  by  four 
traverses,  and  the  entire  frame  is  covered  with  ducking, 
twenty-four  inches  in  width.  Thus  constructed,  the  appa- 
ratus is  not  only  very  light,  SQhthat  any  one  may  easily 
carry  it,  or,  indeed,  even  three  or  four  at  a  time,  but  re- 
markably convenient  both  for  the  transportation  of  patienvs, 
and  for  lifting  them  in  and  out  of  the  wagons,  which  should 
.ilways  be  at  hand  during  and  engagement.  Moreover,  by 
means  of  side  straps,  provided  with  buckles,  il  will  answer 
extremely  well  for  a  bed-chair,  so  necessary  in  sickness  and 
during  convalescence,  the  angle  of  flexion  of  the  two 
pieces  thus  admitting  of  ready  regulation.  In  carrying  the 
wounded  off  the  field,  the  labor  may  easily  be  performed 
by  two  men,  especially  if  they  use  shoulder-straps  to  difiuse 
the  weight  of  the  burden.  The  body,  in  hot  weather, 
might  be  protected  with  an  oil-cloth,  while  the  lace  might 
be  shielded  from  the  sun  with  a  veil  or  handkerchief.  A 
pillow  for  the  head  can  be  made  with  the  coat  of  one  of 
the  carriers. 

Besides  these  means,  every  regiment  should  be  furnish- 
ed with  an  ambulance,  or,  as  the  term  literally  implies,  a 
movable  hospital,  that  is,  a  place  for  the  temporary  accom- 
modation and  treatment  of  the  wounded  on  the  field  of 
battle.  It  should  be  arranged  in  the  form  of  a  tent,  and  be 
provided  with  all  the  means  and  appliances  necessary  for 
the  prompt  succor  of  the  sufferers.  The  materials  of  which 
it  consists  should  be  as  light  as  possible,  possess  every 
facility  for  rapid  packing  and  erection,  and  be  conveyed 
from  point  to  point  by  a  wagon  set  apart  for  this  object. 
The  ambulance,  for  the  invention  and  improvement  of 
which  we  are  indebted  to  two  eminent  French  military  sur- 
geons, Percy  and  Larrey,  is  indispensable  in  every  well- 
regulated  army. 

This  temporary  hospital  should  be  placed  in  an  open 
space,  convenient  to  water,  and  upon  dry  ground,  with  ar- 
rangements for  the  free  admission  of  air  and  light,  which. 


Military  tSurgen/.  lo 

next  to  pure  air,  is  one  of  the  most  powerful  stimulants  in 
all  cases  of  accident  attended  with  excessive  prostration. 
The  direct  ra^^s  of  the  sun,  in  hot  weather,  must  of  course 
be  excluded,  and  it  may  even  be  necessary,  as  in  injuries  of 
the  head  and  eye,  to  wrap  the  patient  in  complete  darkness. 
A  proper!}'  regulated  temperature  is  also  to  be  maintained, 
a  good  average  being  about  68°  of  Fahrenheit's  ther- 
mometer. 

As  engagements  are  sometimes  begun  after  dark,  or  are 
continued  into  the  night,  an  adequate  supply  of  wax  can- 
dles should  be  provided,  as  they  will  be  found  indispensa- 
bbiboth  in  field  and  hospital  practice,  in  performing  opera- 
tions and  dressing  wounds  and  fractures.  Torches,  too,  will 
frequently  be  needed,  especially  in  collecting  and  trans- 
porting the  \AK)unded.  Bed-pans,  feeding-cups,  spoons, 
syringes,  and  other  appliq^nces  usually  found  in  the  sick 
chamber,  will  form  a  necessary  part  of  the  furniture  of 
such  an  establishment. 

Tiie  object  of  the  ambulance  is,  as  already  stated,  to 
atibrd  prompt  succor  to  the  wounded.  Here  their  lighter 
injuries  are  speedily  dressed,  and  the  more  grave  subjected 
to  the  operations  necessary  for  their  cure.  In  due  time, 
the  former  are  sent  bnck  to  the  ranks,  while  the  rest  are 
conveyed  to  suitable  lodgings  or  to  permanent  hospitals. 

As  soon  as  practicable,  after  the  huny  and  confusion 
attendant  upon  a  combat  are  oVer,  the  surgeon  should  clas- 
sify the  wounded  and  disabled,  taking  care  that  those 
laboring  under  similar  lesions  are  not  brought  in  close  con- 
tact ;  lest,  witnessing  each  other's  suft'erings,  they  should 
be  seized  with  fatal  despondency. 

Larrey,  in  order  to  meet  the  exigencies  of  the  grand 
array  in  Italy,  constructed  aflyinj  amhidance  ;  an  immense, 
and,  at  first  sight,  a  very  cumbersome  establishment.  It 
consisted  of  twelve  light  wagons,  on  easy  springs,  for  the 
transportation  of  the  wounded  ;  some  with  two,  others  with 
four  wheels.  The  frame  of  the  former,  which  were  design- 
ed for  flat,  level  countries,  resembled  an  elongated  cube, 
curved  on  the  top ;  it  had  two  small  windows  on  each  side, 
with  a  folding  door  in  front  and  behind.  The  floor  of  the 
body,  separable  and  movable  on  rollers,  was  covered  with  a 
mattress  and  bolster.  Handles  were  secured  to  it  laterally, 
through  which  the  sashes  of  the  soldiers  were  passed  ni 
lifting  the  sick  in  and  out  of  the  carriage,  when,  on  account 
of  the  weather,  their  wants  could  nof  be  relieved  on  the 


16  Military  ia'urgeri/. 

£:roun(l.  Each  vehicle  was  thirty-two  inches  wide,  and  wab 
drawn  by  two  horses  ;  it  could  conveniently  accommodate 
two  patients  at  full  length,  and  was  furnished  with  several 
side-pockets  for  such  articles  as  might  be  needed  for  the 
sutferers. 

The  large  carriage,  drawn  by  four  horses,  and  dcrjigned 
for  rough  and  hilly  roads,  was  constructed  upon  the  same 
principle  as  the  small ;  it  had  four  wheels,  and  could  ac- 
commodate four  persons.  The  left  side  of  the  body  had 
two  long  sliding-doors,  extending  almost  its  whole  length, 
so  as  to  permit  the  wounded  to  be  laid  in  a  horizontal  po- 
sition. 

These  carriages  were  used  for  conveying  the  wounded 
from  the  lield  of  battle  to  the  hospitals  of  the  lines,  and 
combined,  it  is  said,   solidity  with  lightness  and  elegance. 

The  number  of  men  attached  to  the  flying  ambulance 
was  113,  embracing  a  soldier's  guard  with  twelve  men- on 
horseback,  a  quartermaster-general,  a  surgeon-major,  with 
his  two  assistants  and  twelve  mates,  a  police  ollicer,  and  :\ 
number  of  servants.  The  flying  ambulance  was,  in  fact,  a 
costly  and  imposing  establishment,  devised  by  the  humani- 
ty and  ingenuity  of  the  great  and  good  Larrey,  who  could 
never  do  too  much  for  the  wounded  soldier,  and  whose 
presence,  like  that  of  his  illustrious  countryman,  Pare,  al- 
ways served  to  animate  the  French  troops.  At  one  time 
three  divisions  of  the  flying  ambulance,  equipped  upon 
this  grand,  scale,  were  upon  the  fleld  in  ditterent  parts  oi" 
Italy. 

It  is  not  deemed  necessary  in  a  work  like  this,  to  give 
an  nccount  of  the  construction  of  hospitals,  properly  so 
termed ;  for,  with  the  railroad  and  steamboat  facilities 
which  we  now  possess,  there  can  bo  little  difficulty  in  ob- 
taining comfortable  accommodations  for  the  sick  and 
wounded  soldiers.  Lodgings  can  almost  always  be  pro- 
cured, in  nearly  every  portion  of  the  country  where  a  battle 
is  likely  to  be  fought,  in  houses,  churches,  and  barns. 
Temporary  sheds  might  easily  be  erected  in  a  few  hours, 
with  such  arrangements  as  would  serve  for  the  more  press- 
ing wants  of  the  wounded.  The  chief  |)oints  to  be  attended 
to,  in  their  construction,  are  sufficient  elevation  oi'  the 
ground  floor  for  the  free  circulation  of  air,  windows  for 
light  and  ventilation,  and  such  a  position  of  the  flre-place 
as  not  to  annoy  the  inmates. 

The  medical  stores  of  the  military  hospital,  whether  tern- 


Miliiary  Sargenj.  17 

porary  or  permanent,  include  medicines,  instruments,  and 
various  kinds  of  apparatus,  as  bandages,  oiled  Bilk,  and 
splints. 

It  would  far  transcend  my  limits  were  I  to  enter  fully 
into  all  the  details  connected  with  these  difterent  topics. 
A  few  brief  remarks  under  each  head  must  suffice  for  my 
purpose. 

1st.  In  regard  to  incdicines,  a  few  articles  only,  well  se- 
lected and  arranged  for  ready  use,  will  be  necessary.  It  is 
bad  enough,  in  all  conscience,  for  a  man  to  be  severely  shot 
or  stabbed,  without  physicking  him  to  death.  Let  him  bj^ 
all  means  have  a  chance  for  his  life,  especially  when  he  has 
already  been  prostrated  by  shock  and  hemorrhage.  Fi'od 
and  drink,  with  opium  and  fresh  air,  will  then  do  him  more 
good  than  anything  else.  I  shall  enumerate  the  medicines 
upon  which,  in  my  judgment,  most  reliance  is  to  be  placed 
in  this  kind  of  practice,  according  to  their  known  effects 
upon  the  system. 

1.  Anodynes : — opium,  morphia,  and  black  drop,  or 
acetated  tincture  of  opium. 

2.  Purgatives : — blue  mass,  calomel,  rhubarb,  jalap, 
compound  extract  of  colocynth,  and  sulphate  of  magnesia. 
Some  of  these  articles  should  be  variously  combined,  and 
put  up  in  pill  form  for  ready  use. 

J}.  Depressants  ; — tartrate  of  antimony  and  potassa,  ipe- 
cacuanha, and  tincture  of  vcratrum  viride. 

4.  Diaphoretics: — antimom',  ipecacuanha,  nitrate  of  po- 
tassa, morphia,  and  Dover's  powder. 

').  Diuretics: — nitrate  and  carbonate  of  potassa,  and  col- 
chicum. 

0.  Antiperiodics  : — quinine  and  arsenic. 

7.  Annesthetics: — chloroform  and  ether. 

8.  Simulants  : — brandy,  gin,  wine,  and  aromatic  spirits 
of  ammonia. 

9.  Astringents : — acetate  of  lead,  perchloride  of  iron  and 
alnm,  tannin,  gallic  acid,  and  nitrate  of  silver. 

10.  Escharotics: — nitric  acid,  acid  nitrate  of  mercury, 
(Bennett's  formula,)  and  Vienna  paste. 

2d.  The  Hurg\ca\  armameniarium  should  also  be  as  simple 
as  possible.  It  should  embrace  a  small  pocket  case,  with 
a  screw  catheter;  a  full  amputating  case,  with  at  least  three 
tourniquets,  two  saws  of  different  sizes,  and  several  largo 
bone-nippers ;  and,  lastly,  a  trephining  case.  Several  silver 
oathcters   of  different  sizes,   a  stomach   pump,  small  and 


18  Military  Surgery. 

large  syringes,  feeding-cajts  and  bed-pans  should  also  be 
put  up. 

3d.  Under  tbc  head  of  apparatus  may  be  included  banda- 
ges, lint,  linen,  adhesive  plaster,  splints,  cnsliions,  wadding, 
and  oiled  silk. 

The  bondages,  composed  ot  tolerably  stout  muslin,  should 
be  free  from  starch  and  selvage,  Avell  rolled,  on  an  average, 
trom  two  inches  and  a  quarter  to  two  inches  and  a  half  in 
width  by  eight  yards  in  length.  The  bandage  of  Scultetus, 
very  serviceable  in  compound  factures,  can  easily  be  made, 
as  occasion  my  require,  out  of  pieces  of  the  common  roller. 

Of  lint,  the  patent,  or  apothecary's,  as  it  is  termed,  is  the 
the  best,  as  it  is  soft  and  easily  adapted  to  the  parts  to  which 
it  is  intended  to  be  applied.  Old  linen  or  muslin  also  an- 
swers sufficiently  well.     Charpie  is  now  seldom  used. 

An  abundance  of  adhesive  j^lasicr,  put  up  in  small  cases, 
should  be  provided.     Collodion  will  not  be  necessary. 

Splints,  of  binders  or  trunk-maker's  board,  and  of  light 
wood,  should  find  a  place  in  every  medical  store,  as  fre 
quent  occasions  occur  for  their  use.  In  fractures  of  the 
lower  extremity  special  apparatus  may  be  required,  which, 
however,  as  it  is  cumbrous  and  inconvenient  to  carry,  may 
generally  be  prepared  as  it  is  needed. 

Cc.^hions  are  made  of  muslin,  sewed  in  the  form  of  bags, 
of  variaVde  size  and  shape,  and  filled  with  cotton,  tosv,  saw- 
dust or  sand.  They  are  designed  to  equalize  and  ward  off 
pressure  in  the  treatment  of  fractures  of  the  lower  ex- 
tremities. 

Wtiddi>}f/  is  a  most  valuable  article  in  surgical  practice, 
both  for  lining  splints  and  making  pads,  as  well  as  in  the 
treatment  of  burns  and  scalds,  and  cannot  be  dispensed 
with. 

Oiled  Silk  is  a  prominent  article  in  the  dressings  of  the 
present  day ;  it  preserves  the  heat  and  moisture  of 
poultices  and  of  warm  water-dressings,  at  the  same  time 
that  it  protects  the  bed  and  body-clothes  of  the  patient. 

Oil-doth,  soft  and  smooth,  is  required  In  all  cases  of  severe 
wounds  and  fractures,  attended  with  much  discharge. 

Air-cushions  should  be  put  up  in  considerable  numbers, 
as  their  use  will  be  indispensable  in  all  cases  of  disease  and 
injury  involving  protracted  confinement. 

Bran  and  saw-dust  will  be  found   of  great  value  in  the 
catment  of  compound   fractures,   ulcers,   gangrene, .  and 


MiUtaiy  Surrjert/.  19 

suppurating  wounds,  as  an  easy  support  for  the  injured 
limb  and  a  means  of  excluding  liies. 

Medical  case-books  should  be  put  up  along  witli  the  other 
articles,  for  the  accurate  registration  of  the  names  of  the 
sick  and  wounded,  the  nature  of  their  lesions,  and  the  re- 
sults of  treatment.  The  medical  officers  should  also  keep 
a  faithful  record  of  the  state  of  the  weather,  the  tempera- 
ture of  the  air,  the  nature  of  the  climate,  the  products  of 
the  soil,  and  the  botany  of  the  country  through  which  they 
or  in  which  they  sojourn,  together  with  such  matters  as 
may  be  of  professional  or  scientific  interest.  The  knowl- 
edge thus  acquired  should  be  disseminated  after  their  re- 
turn for  the  benefit  of  their  professional  brethren. 

Finally,  in  order  to  complete  hospital  equipments,  well- 
trained  nurses  should  be  provided  ;  for  good  nursing  is  in- 
dispensable in  every  case  of  serious  disease,  whatever  may 
be  its  character.  The  importance  of  this  subject,  however, 
is  now  so  well  appreciated  as  not  to  require  any  special 
comments  here. 

The  question  as  to  whether  this  duty  should  be  perform- 
ed by  men  or  women  is  of  no  material  consequence,  pro- 
vided it  be  well  done.  The  eligibility  of  women  for  this 
task  was  thoroughly  tested  in  the  Crimea,  through  the  agen- 
cy of  that  noble-hearted  female,  Florence  Nightingale  ;  and 
hundreds  of  the  daughters  of  our  land  have  already  tendered 
their  services  to  the  government  for  this  object.  Xo  large 
and  well  regulated  hospital  can  get  on  without  some  male 
nurses,  and  theyare  indispensable  in  campand  field  practice. 

It  is  not  my  purpose  here  to  point  out  the  qualities  which 
constitute  a  good  female  nurse.  It  will  suffice  to  say  that 
she  should  be  keenly  alive  to  her  duties,  and  perform 
them,  however  menial  or  distasteful,  with  promptness  and 
alacrity.  She  must  be  tidy  in  her  appearance,  with  a 
cheertul  countenance,  light  in  her  step,  noiseless,  ten- 
der and  thoughtful  in  ner  manners,  perfect  mistress  of 
her  feelings,  healthy,  able  to  bear  fatigue,  and  at  least 
twenty-two  years  of  age.  ISTeither  the  crinoline  nor  the 
silk  dress  must  enter  into  her  wardrobe  ;  the  former  is 
too  cumbrous,  while  the  latter  by  its  rustling  is  sure  to  fret 
the  patient  and  disturb  his  sleep.  Whispering  and  walking 
in  on  tiptoe,  as  has  been  truly  observed  by  Florence  Night- 
ingale, are  an  abomination  in  the  sick  chamber.  Finally, 
a  good  nurse  never  fails  to  anticipate  all,  or  nearly  all,  the 
more  important  wants  of  the  sufferer. 

Among  other  things  to  be  specially  attended  to  in  nurs- 


20  Military  S^rgay. 

ing  is  ventilaiton.  Persons  visiting  the  sick  must  a  tonee  be 
struck  with  the  difference  of  pure  air  in  those  chambers 
Avhere  a  proper  ventilation  exists  and  those  where  tlie  re- 
verse is  the  case.  To  insure  this  the  fresh  air  sliould 
always  be  admitted  from  a  window  not  open  directly  on  the 
bed,  or  causing  the  patient  to  be  in  a  draught.  Even  in 
winter  it  is  hig^ily  proper  that  fresh  air  should  be  admitted 
some  time  during  the  day  when  tlicre  is  a  good  lire  and  the 
patient  well  protected  by  covering. 

The  pillows,  bedding,  and  bedclothes  should  be  well 
aired  and  often  changed,  as  also  the  flannel,  nnder-gar- 
ments,  and  night-dress.  To  facilitate  this,  it  is  well,  when 
the  patient  is  very  ill  and  unable  to  help  himself,  to  have  the 
shirt  open  all  the  way  down  in  front,  and  buttoned  up.  The 
patient  often  escapes  great  suflcring  and  annoyance  by  this 
simple  method.  Where  there  is  a  discharge  from  the  sores, 
or  when  water-dressing  arc  applied  to  a  limb,  it  is  advisa- 
ble to  place  the  latter  iipon  a  folded  sheet  with  a  thin,  soft 
oil-cloth  underneath.  Great  tenderness  and  cleanliness 
should  be  used  in  dressing  wounds  or  sores.  Old  linen, 
muslin,  and  lint  should  always  be  had  in  readiness  for  this 
purpose.  A  great  prejudice  exists  against  the  use  of  mus- 
lin, the  preference  being  generality  given  to  linen,  but  the 
former  is  roallv  quite  as  go«d  as  the  other,  if  it  is  soft  and 
old. 

In  regard  to  the  cleanliness  of  a  sick-room,  it  is  advisabk' 
to  use  a  mop  occasionally  for  the  removal  of  flue  from  un- 
der the  bed  ;  when,  however,  the  patient  is  in  too  critical  a. 
situation  for  dampness,  a  few  tea-leaves  scattered  over  the 
apartment  will  absorb  the  dust,  andean  be  quictly_  taken 
up  with  a  hand-brush.  A  frequent  change  of  bed  linen  is 
very  beneficial  when  practicable,  and  the  clothes  must  al- 
ways be  folded  smoothly  under  the  patient.  Great  clean- 
liness should  be  observed  in  all  the  surroundings  of  the 
sick-room,  and  particular  attention  must  be  paid  to  the 
glasses  in  which  medicine  is  given,  in  order  to  render  the 
doses  as  palatable  as  possible.  The  patient  should  be 
washed  whenever  able,  and  his  teeth  and  hair  well  attend- 
ed to.  The  body  eeems  infused  with  new  vigor  after  such 
ablutions. 

A  frequent  change  of  posture  is  immensely  conducive  to 
the  comfort  and  well-being  of  a  sick  person,  if  performed 
with  a  careful  eye  to  his  particular  condition.  Severe  pain, 
loss  of  sleep,  excessive  confititutioual  irritation,  and  dread- 


3Iililarf/  Sarffcvii.  2l 

fill  bed-soros  are  sure  to  follow,  in  all  low  states  of  the 
system,  if  tliis  precaution  be  not  duly  heeded.  No  patient 
must  have  his  head  suddenly  raised,  or  be  permitted  to  lie 
high,  when  he  is  exhausted  from  shock,  hemorrhage,  or 
siclcness.     ]Many  lives  have  been  lost  by  this  indiscretion. 

The  apartment  must  be  free  from  noise,  the  light  should 
neither  be  too  freely  admitted  nor.  too  much  exchuled,  ex- 
cept in  head  and  eye  affections,  and  the  temperature  must 
be  regulated  by  the  thermometer,  from  65°  to  68°  of 
Fahrenheit  being  a  proper  average. 

As  the  patient  acquires  strength,  he  may  gradually  sit 
up  in  bed,  propped  up  at  first  by  pillows,  and  afterward  by 
a  bed-chair. 

His  food  and  drink,  and  also,  at  times,  his  medicine, 
must  be  given  from  a  feeding-cup  during  the  height  of  his 
disease,  and  a  good  general  rule  is  to  administer  tliem  with 
great  regularity,  provided  this  does  not  interfere  too  much 
with  his  repose.  If  he  is  very  weak,  and  sleeps  very  long, 
it  will  be  necessary  to  wake  him  in  order  to  give  him 
nourishment;  but,  in  general,  sleep  is  more  retVeshing 
than  food,  and  more  beneficial  than  medicine.  The  bed- 
pan and  urinal  of  course  find  their  appropriate  sphere  un- 
der such  circumstances. 

As  the  appetite  and  strength  increase,  the  piitient  is  per- 
mitted to  resume,  though  very  gradual h',  his  accustomed 
diet  and  to  exercise  about  the  room,  if  not  in  the  ojteM  air. 
After  severe  accidents  and  protracted  sickness,  a  wise  man 
will  not  bestir  himself  too  soon  or  too  much,  but  court  the 
fickle  goddess  of  health  with  becoming  caution. 

J)ying  patients  should  be  carefully  screened  from  their 
neighbors,  placed  in  the  easiest  posture,  have  free  access 
of  air,  and  be  not  disturbed  by  noise,  loud  talking,  or  the 
presence  of  persons  not  needed  for  their  comfort.  As 
soon  as  the  mortal  struggle  is  over,  the  body  must  be  re- 
moved. 

The  excretions  should  be  removed  as  speedily  as  possible 
from  the  apartment,  and  the  vessels  in  which  they  are  re- 
ceived immediately  well  scalded,  the  air  being  at  the  same 
time  perfectly  purified  by  ventilation,  or  ventilation  and 
disinfectants. 

Finally,  the  nurse  must  take  care  of  herself.  She  must 
have  rest,  or  she  will  soon  break  down.  If  she  is  obliged 
to  be  up  all  night,  she  should  be  spared  in  the  day. 


til!  Military  Surgery. 

OIIAPTEll  V. 

WOUNDS    AND    OTUER    IX.IUKIE5.. 

The  iiijui'Icn  inflicted  in  war  :ire,  iu  every  respect,  .-iniilar 
lo  those  received  in  civil  lite.  The  uisst  common  and  impor- 
tant are  fractures,  dislociitions,  bruises, sprains, burnf^nnd  the 
different  kinds  of  v/ounds,  as  the  incised,  punctured,  lacer- 
ated, and  gunshot.  AVith  the  nature,  diagnosis,  and  mode 
of  treatment  of  these  lesions  every  army  surgeon  must,  of 
course,  bo  supposed  to  be  l\wniliar;  and  I  shall  therefore 
limit  myself,  in  the  remarks  which  I  am  about  to  offer 
upon  these  subjects,  to  a  few  practical  hints  respecting  their 
management  on  the  iield  of  battle  and  in  the  ambulance. 

Most  of  the  cases  ot'fracUires  occurring  on  the  field  of 
battle  are  the  result  of  gunshot  injury,  and  are  frequently, 
if  not  generally,  attended  by  such  an  amount  of  injury  to 
the  soft  parts  and  also  to  the  bone  as  to  demand  amputa- 
tion. The  bone  is  often  drcadtully  comminuted,  and  con- 
sequently utterly  unfit  for  preservation.  The  more  simple 
fractures,  on  the  contrary,  readily'  admit  of  the  retention  of 
the  limb,  without  risk  to  life. 

In  tronsporting  persons  affected  witli  fractures,  whether 
simple  or  complicated,  the  utmost  care  should  be  used  to 
render  them  as  comfortable  as  possible,  by  placing  the  in- 
jured limb  in  an  easy  position,  and  applying,  if  need  be,  on 
account  of  the  distance  to  which  they  have  to  be  carried, 
or  the  mode  of  conveyance,  short  side  splints  of  binders' 
board,  thin  wood,  as  a  shingle,  or  junks  of  straw,  gently 
confined  by  a  roller.  For  want  of  duo  precaution  the  dan- 
ger to  limb  and  life  may  be  materially  augmented.  Per- 
manent dressings  should  be  applied  at  the  earliest  moment 
after  the  patient  reaches  the  hospital.  If  the  fracture  be 
attended  with  fjplintering  of  the  bone,  all  loose  or  detached 
pieces  should  at  once  be  extracted ;  a  proceeding  which 
always  wonderfully  simplifies  the  case,  inasmuch  as  it  pre- 
vents, in  a  great  measure,  the  frightful  irritation  and  sup- 
puration which  arc  sure  to  ibllow  their  retention.  When 
this  point  has  been  properly  attended  to,  the  parts  should 
be  neatly  brought  together  by  suture,  and  covered  with  a 
compress  wet  with  blood.  As  soon  as  inflammation  arises 
— not  before — water-dressings  are  employed.  A  euitable 
opening,  or  bracket,  should  be  made  in  the  apparatus  to 
facilitate  drainage  and  dressing". 


MUita.rii  Hiifijcni. 


■)X 


Dislocatiotis,  accidents  by  no  means  common  in  niili  ary 
operations,  arc  treated  according  to  the  general  rules  of 
practice;  they  should  be  speedily  reduced,  without  the  aid 
of  chloroform,  if  the  patient  is  faint  or  exhausted  ;  with 
chloroform,  if  he  is  strong  or  reaction  has  been  fully  estab- 
lished. The  operation  may  generally  be  successfully  per- 
formed by  simple  manipulation  ;  if,  however,  the  case  is 
obstinate,  pulleys  may  be  necessary,  or  extension  and  coun- 
ter-extension made  by  Judicious  assistants. 

Bruises,  or  contusions,  unless  attended  with  pulpilication, 
disorganization,  or  destruction  of  the  tissues,  are  best  treat- 
ed, atlirst,  until  the  pain  subsides  with  tepid  water  impreg- 
nated with  laudanum  and  sugar  of  lead,  or  some  tepid 
spirituous  lotion,  and  afterward,  especially  if  the  patient  be 
strong  and  robust,  with  cold  water,  or  cold  a'stringent  tiuids. 
If  the  injury  be  deep  seated,  extensive,  and  attended  with 
lesion  ot  very  important  structures,  the  case  will  be  a  seri- 
ous one,  liable  to  be  followed  by  the  worst  consequences, 
requiring,  perhaps,  amputation. 

Sprains  arc  often  accompanied  with  excessive  pain  ami 
even  severe  constitutional  symptoms.  They  should  be 
treated  with  the  free  use  of  anodynes  and  with  warm  water- 
dressings  medicated  with  laudanum,  or  laudanum  and  lead. 
The  Joint  must  be  elevated  and  kept  at  rest  in  an  easv 
position.  Leeches  may  be  applied,  if  they  can  be  obtained ; 
otherwise,  if  plethora  exist,  blood  may  be  taken  from  the 
the  arm.  B\'-and-by  sorbefacient  liniments  and  friction 
come  in  play.  Passive  motion  should  not  be  instituted  too 
soon. 

Among  the  accidents  of  war  are  burns,  and,  occasionally, 
also  scalds.  The  former  may  be  produced  by  ordinary  fire 
or  by  the  explosion  of  gunpowder,  either  casual  or  from  the 
blowing  up  of  redoubts,  bridges,  bouses,  or  arsenals,  and 
varj'  from  the  trivial  to  the  most  serious  lesions,  involving 
a  great  extent  of  surface  or  of  tissue,  and  liable  to  be  follow- 
ed by  the  w^orst  consequences.  Such  injuries  always  re- 
((uire  prompt  attention  ;  for.  apart  from  the  excessive  pain 
and  collapse  which  so  often  accompany  them,  the  longer 
they  remain  uncared  for  the  more  likely  will  they  be  to  end 
badly. 

Various  remedies  have  been  proposed  for  these  injuries. 
I  have  myself  always  found  white-lead  paint,  such  as  that 
employed  in  the  arts,  mixed  with  linseed  oil  to  the  consist- 
ence of  very  thick  cream,  and  applied  so  as  to  form  a  eom- 


24  Mili/ai-'/  Scrt/ciy. 


...  V^   .o»    -N.^ 


pTctc  coating,  the  most  soothing- and  efficient  moans.  The 
•  Irossing  is  tiiiislicd  ])y  cnvelopinii^  tlio  p:)rts  in  -waddino^,  con- 
lino<l  l)v  a  modcratolv  tii^lit  roller,  it  should  not  1)0  ro- 
rnovc'd,  unless  there  is  much  <liseluirgc  or  swelliuii;,  lor 
several  days.  If  vcsielos  exist,  they  should  previously  be 
opened  with  a  needle  or  the  point  of  a  histoury.  A  lini- 
ment or  ointment  of  glycerin,  lard  or  simple  cerate,  and 
suhnitrate  of  hismuth,  as  suggested  by  my  friend,  I'rofes- 
sor  T.  (J.  liiehardson.  of  Xew  Orleans,  is  also  an  exeelleni 
remedy,  and  may  be  nsedin  the  same  manner  as  the  white 
lead  ]taint.  hi  the  milder  eases,  carded  cotton,^  cold  water, 
and  alcohol,  water  and  laudanum,  generally  atfowl  prompt 
i-elief.  Amputation  will  be  necessary  wlien  thci-e  i.s  exten- 
sive destruction  of  the  muscles,  bones  or  joints.  Reaction 
must  be  promoted  by  the  cautious  >ise  oH  stimulants: 
while  pain  is  allayed  by  morphia  or  laudanum  given  Avith 
more  than  ordinary  cirenmspeetion.  lest  it  induce  fatal  op- 
pression of  the  brain. 

In  burns  from  the  explosion  oi'  ijiuipoirder,  particles  of 
this  substance  arc  often  buried  in  the  skin,  where,  if  it  be 
not  removed,  they  leave  disfiguring  marks.  The  best  way 
to  get  rid  of  them  is  to  pick  out  grain  after  grain  with  the 
point  of  a  narrow-bladed  bistoury  or  cataract  needle. 

The  suliject  of  wotinds  is  a  mo8t  important  one  in  regai-d 
to  iield  practice,  as  these  lesions  arc  not  only  of  fre(|ueni 
occurrence,  but  present  themselves  in  every  vaiicty  of  form 
and  extent.  Their  i^-ravitv  is  influenced  bv  numerous  cir- 
cumstances  which  our  space  docs  not  penait  us  to  speedy, 
but  which  the  intelligent  reader  can  readily  appreciate.  In 
many  cases  death  is  instantaneous,  owing  to  shock,  or  shock 
and  liemorrhage ;  in  others  it  cccurs  gradnally  with  or 
without  i-eaction,  at  a  ]>eriod  of  several  hours,  or,  it  may  be, 
not,  under  several  days.  Sometimes  men  are  destroyed  by 
shock,  by,  apparently,  tlic  most  insignitieant  wound  or 
injury,  owing,  not  to  wantoi  courage,  but  to  some  idiosyn- 
rracy. 

The  indications  presented  in  all  wounds,  of  whaterer  na- 
ture, arc — 1st,  to  relieve  shock  ;  2dly,  to  arrest  hemorrhage ; 
JJdly,  to  remove  foreign  matter ;  4th,  to  approximate  an<l 
retain  the  parts;  and,  5thly,  to  limit  the  resulting  intlani- 
mation. 

1.  It  is  not  necessary  to  describe  minutely  the  symptoms 
i)i'  shoe/,;  as  the  nature  of  tho  case  is  suiHcicntly  obvious  at 
tirst  siglil.  Ironi  lli<' <'\'c('ssiv<'  pallor  of  ihf  (■ouiit(Miance.the 


MiUlary  Surgcr}/.  25 

wcukcuod  or  absent  pulse,  the  confused  istate  of  tlie  mind, 
the  nausea,  or  nausea  and  vomiting,  and  the  excessive 
l)odily  prostration.  The  case  must  be  treated  promptly ;  by 
free  access  of  fresh  air  and  the  use  of  the  fan,  by  looseninii-' 
the  dress  or  the  removal  of  all  sources  of  constriction,  by 
dashing  cold  water  into  the  face  and  upon  the  chest,  by 
recumbency  of  the  head,  and  by  di-aught  of  cold  water,  or 
water  and  spirits,  wine  or  hartshorn,  if  the  patient  can 
swallow;  aided,  if  the  case  be  urgent,  by  sinapisms  to  the 
region  of  the  lieart,  tlie  inside  of  thighs  and  the  spine,  and 
stimulating  injections,  as  brandy,  turpentine,  mustard,  or 
ammonia,  in  a  few  ounces  of  water.  Xo  lluid  must  be  put 
into  the  mouth  so  long  as  the  power  of  <.leglutition  is  gone, 
lest  some  of  it  should  enter  the  windpipe,  and  so  occasion 
sultbcation.  Whatever  the  cause  of  the  shock  may  have 
been,  let  the  medical  aiteiuhmt  not  fail  to  encourage  the 
sullerer  by  a  kind  and  soothing  expression,  Avhich  is  often 
of  more  value  in  rcenlling  animation  than  the  best  cordials. 

During  an  actual  engagement,  the  medical  otticers,  as 
well  as  their  servants,  should  carry  in  tlieir  pockets  such 
articles  as  the  wounded  will  l)e  most  likely  to  need  on  the 
field  of  battle,  as  brandy,  aromatic  s]iirits  of  hartshorn,  and 
juorphia,  put  up  in  suitable  doses. 

2.  The  la:uiorrha<ic.  may  be  ailerial  Vr  \eiious,  or 
both  arteri.'d  and  venous,  slight  or  profuse,  primai'y  or 
secondary,  external  or  internal,  'i'he  scarlet  color  and  sal- 
tatory jet  will  inform  tis  wheii  it  is  arterial;  tlie  purple  hue 
and  steady  How,  when  it  is  venous.  When  the  woun<l  is 
severe,  or  involving  a  large  artery  or  vein,  or  even  middle- 
sized  vessels,  the  bleeding  may  prove  tiitalin  a  few  mi)iutes 
uidess  immediate  assistance  is  rendered.  Hundreds  of  ]tcr- 
sons  die  on  the  field  of  ])attle  from  this  cause.  They  alloM 
their  life  current  to  run  out,  as  water  pours  Irom  a  hydrant, 
without  an  attempt  to  stop  it  by  thrusting  the«tinger  in  tlie 
wound,  or  compressing  the  main  artery  of  the  injured  limit. 
They  perish  simply  from  their  ignorance,  because  the  regi- 
mental surgeon  has  failed  to  give  the  proper  instruction.  \i 
is  not  necessary  that  the  common  soldier  should  cai-ry  a 
l^etifs  tourniquet,  but  every  one  may  put  into  his  pocket  a 
stick  of  wood,  six  inches  long,  and  a  handkerchief  or  piece  (»l 
roller,  with  a  thick  compress,  and  be  advised  how,  wheiv. 
and  when  they  are  to  bo  used.  By  casting  the  handkcr- 
•  •hief  round  the  limb,  and  placing  "the  compress  over  its 
maiji  ai-tery,  he  can,  1)y  means  of  the  stick,   produce   such 


26  Military  Surgery. 

an  amount  of  compression  as  to  put  at  once  an  effectual 
rttop  to  tlie  lieiiiorrliap^e.  Tliis  pimple  contrivance,  which 
hasheen  inKtriimental  in  saving  thousands  of  lives,  consti- 
tutes what  is  called  the  field  fonrnifixet.  A  iife,  drum-stick, 
knife  or  nuiir<^(l  may  he  used,  it  no  sjio«Ma1  ]uccc  of  woo<l 
is  at  hand. 

Tlic  most  rcliahlc  means  for  arresting  lieuiorrhage  ]»er- 
manently  is  the  /ii/aO'.rc,  of  strong,  delicate,  well-waxed  silk- 
well  applied,  with  one  end  cut  off  close  to  the  knot.  A  cu, 
[tressurc  is  hardly  a  proper  exioedient  upon  the  battle-field, 
or  in  the  ambulance,  especially  when  the  number  of  wound- 
«'d  is  considerable.  The  rule  invariably  is  to  tic  a  Avounded 
artery  both  above  and  below  tlie  seat  of  injurys  lest  recur- 
rent bleeding  should  arise.  Another  equally  obligatory 
precejtt  is  to  ligature  the  vessels,  if  practicable,  at  the  place 
whence  the  blood  issues,  by  enlarging,  if  need  be,  the 
original  wound.  The  main  trunk  of  the  artery  should  be 
secured  only  when  it  cannot  be  taken  up  at  the  point  just 
mentioned.  Lastly,  it  is  hardly  recpiisite  to  add  that  the 
i)peration  should  be  performed,  with  the  aid  of  the  tourni- 
quet, as  early  as  possible,  before  the  supervention  of  infiam- 
niation  and  swelling,  which  must  necessarh^'  obscure  the 
parts  and  increase  the  surgeon's  embarrassment,  as  well  as 
tiie  patient's  paili  and  risk. 

Venous  hemorrhagic  usually  stops  spontaneously,  or  readi- 
ly yields  to  compression,  even  when  a  large  vein  is  impli- 
cated. The  ligature  should  be  employed  only  in  the  event 
of  absolute  necessity,  for  fear  of  inducing  undue  inflamma- 
tion. 

Torsion  is  unworthy  of  confidence  in  field  practice,  and 
the  same  is  true  of  stf/pfic-^!,  exrept  when  the  hemorrhage  is 
«'apillary,  or  the  blood  oozes  from  nunnn'ous  points.  The 
most  approved  articles  of  this  kind  are  Monsel's  salt,  or  the 
persulphate  of  iron  and  the  pcrchloride  of  iron ;  the  latter 
deserving  the  preference,  on  account  of  the  superiority  of 
it  hemostatic  properties.  Alum  and  lead  are  inferior  styp- 
tics. 

Temporary  co)))pr(\<tsin/)  may  be  made  with  the  tourni(|uet, 
or  a  compress  and  a  roller.  It  may  be  direct,  as  when  the 
conqMvss  is  applied  to  the  orifice  of  the  bleeding  vessel,  or 
indirect,  as  when  it  is  applied  to  the  trunk  of  the  vessel,  at 
son»e  distance  from  the  W(nind. 

Constitutional  treatment  in  hemorrhage  is  of  paramount 
importance.     It  comprises  perfect  tranquility  of  mind    and 


Military  Surge) 

body,  cooling  clriukiJ,  a  mild,  concenrated  nouriahing  diet, 
especially  wlieii  there  has  been  excessive  1ob3  of  blood,  ano- 
dynes to  allay  pain,  induce  sleep,  and  allay  the  heart's  inor- 
dinate action,  fresh  air,  and  a  properly  regulated  light. 

Internal  hemorrhage  is  more  daugerouB  than  external, 
because  it  is  generally  inaccssible.  The  chief  remedies  are 
copious  venesection,  elevated  position, opium  and  acetate  ot 
lead,  cool  air,  and  cool  drinks. 

Exhaustion  from  hemorrhage  sliould  be  treated  accord- 
ing to  the  principles  which  guide  the  practitioner  in  caacR 
of  severe  shock.  Opium  should  be  given  freely  as  soon  as 
reaction  begkis  to  quiet  the  tremulous  movements  of  .the 
heart  and  tranquilize  the  mind.  When  the  bleeding  is  in« 
ternal,  the  reaction  should  be  brought  about  gradually,  not 
hurriedly,  lest  we  thus  become  instrumental  in  promoting  or 
re-exciting  the  hemorrhage. 

[Secondary  hemorrhage  comes  on  at  a  variable  period, 
from  a  few  houi-s  to  a  number  ot  days;  it  may  depend 
upon  imperfect  ligation  of  the  arteries,  ulceration,  softening 
or  gangrene  of  the  coats  of  these  vessels,  or  upon  undue 
constriction  of  the  tissues  by  tight  bandages.  In  some  cases 
it  is  venous,  and  may  then  be  owing  to  inadequate  support 
of  the  parts.  ^Whatever  the  cause  may  be,  it  should  be 
promptly  searched  out,  and  i*emoved. 

3.  The  third  indication  is  to  remove  all  jorC((//i  maitcr. 
This  should  be  done  at  once  and  eliectually ;  with  sponge 
and  water,  jH'essed  upon  the  parts,  with  linger,  or  linger  and 
forceps.  jS  ot  a  particle  of  matter,  not  a  hair,  or  the  smallest 
clot  of  blood  must  be  left  behind,  othei'wise  it  will  bo  sure 
to  produce  and  keep  np  irritation. 

4.  As  soon  as  the  bleeding  has  been  checked  and  the  e.s,- 
iraneous  matter  cleared  away,  the  edges  of  the  vjound  are 
gently  and  evenly  approximated  and  permanently  retained 
by  suture,  and  adhesive  plaster,  aided,  if  necessary,  by  tho 
bandage.  The  best  suture,  because  the  least  irritating,  is 
that  made  of  silver  wire  ;  but  if  this  material  is  not  at  hand, 
strong,  thin,  welUvaxed  silk  is  used.  The  adhesive  stripe- 
are  applied  in  such  a  manner  as  to  admit  of  free  drainage. 
The  bandage  is  required  chiefly  in  injuries  extending  deep- 
ly among  the  muscles  ;  when  this  is  the  case,  its  use' should 
be  aided  by  compresses  arranged  so  as  to  force  together  th^* 
deep  parts  of  the  wound. 

5.  When  the  v;ound  is  dressed,  the  next  duty  of  the  sur- 
geon is  to  moderate  the  resulting  inflammation.    For  thip 


28  31ilitan/  Surffm/. 

purpose  the  ordinary  aiitiphlogastic  means  are  employed. 
In  general,  very  little  medicine  will  be  required,  except  a 
full  anodyne,  as  half  a  grain  of  morphia,  immediately  after 
tlie}>atient  has  sufKciently  recovered  from  the  effects  of  his 
shock,  and  perhaps  a  mild  aperient  the  ensuing  morning, 
especially  if  there  be  constipation  with  a  tendency  to  exces- 
sive reaction.  The  drinks  must  be  cooling,  and  the  diet 
light  and  nutritious,  or  otherwise,  according  to  the  amount 
of  depression  and  loss  of  blood.  In  the  latter  event,  a  rich 
diet  and  milk-j^nuch  maybe  required  from  the  beginning. 
A  diaphoretic  draught  will  be  needed  if  the  skin  is  hot  and 
arid,  aided  by  frequent  sponging  of  the  surface  with  cool  or 
tepid  water.  General  bleeding  will  rarely,  if  ever,  be  re- 
quired ;  certainly  not  if  the  injury  isat  all  severe,  or  if  there 
has  already  been  any  considerable  waste  of  blood  and  nerv- 
ous fluid. 

Much  trouble  is,  at  times,  experiencevl  both  in  civil  and 
military  pi-actice,  especially  in  very  hot  weather,  in  ])revent- 
ing  the  access  ot  flies  to  our  dressing.  The  larva)  which  they 
de})0sit  are  rapidly  developed  into  innnense  ma(/goii>\  which, 
creeping  over  the  wounds  and  sores  of  the  patient,  and  gnaw- 
ing the  parts,  cause  the  most  horrible  distress.  »  The  soldiers  in 
Syria,  under  Larrey,  were  greatly  annoyed  by  these  insects, 
and  our  wounded  in  Mexico  also  suffered  not  a  little  from 
them.  The  best  prevention  is  bran,  or  light  saw-dust,  with 
Mdiich  the  injured  parts  should  be  carefully  covered.  The 
use  of  cotton  must  be  avoided,  inasmuch  as  it  soon  becomes 
hot  and  wet ;  two  circumstances  highly  favorable  to  incuba- 
tion. 

The  best  local  applications  are  the  water-dressings,  either 
tepid,  cool,  or  cold,  according  to  the  temperament  of  the 
])at.ient,  the  tolerance  of  the  parts,  and  the  season  of  the  year. 
Union  by  the  first  intention  is,  in  all  the  more  simple  cases, 
the  thing  aimed  at  and  steadily  kept  in  view,  and  hence  the 
less  the  parts  are  encumbered,  moved  (tr  fretted,  the  more 
likely  shall  we  be  to  attain  the  object. 

The  medical  attendant  should  have  a  constant  eye  to  the 
condition  of  the  bladder  after  all  severe  injuries,  of  whatevei* 
characler,  a?^  retention  ot*  urine  is  an  exti-eraely  common  occm-- 
rence,  and shotdd  always  be  promj^tly  remedied.  Attention 
to  this  point  is  the  more  necessary,  because  the  poor  patient, 
in  his  comatose  or  insensible  condition,  is  frequently  unable 
to  make  known  his  wants. 

Sncli,  in  a  few  words,  are  the  general    }>rinci])les   ol'  treat- 


M'dUary  Siir{)er}j.  29 

lucnt  to  1)0  followed  in  all  wounds ;  but  there  arc  some 
wounds  whieli  are  characterized  by  peculiarities,  and  these 
peculiarities  are  ot  such  ])ractical  importance  as  to  require 
separate  consideration.  Of  this  nature  are  punctured,  lacer- 
ated, and  gunshot  wounds. 

Punctured  u'onnds  are  inflicted  by  various  kinds  of  weapons, 
as  the  lance,  sabre,  sword,  or  bayonet.  In  civil  practice, 
they  arc  most  generally  met  with  as  the  result  of  injur- 
ies inflicted  by  nails,  needles,  splinters,  fragments  of  bone. 
They  often  extend  into  the  visceral  cavities,  joints,  vessels, 
and  nerves;  and  are  liable  to  be  followed  by  excessive  pain, 
erysipelas,  and  tetanus ;  seldom  heal  by  adhesive  action ; 
and  often  cause  death  by  shock  or  iiemorrliage.  When  the 
vulnerating  body  is  broken  off  and  buried,  it  may  be  difficult 
to  find  ami  extract  it,  especially  wdien  small  and  deep  seat- 
ed. AVhen  this  is  the  case,  the  wound  must  be  freely  tli- 
lated,  an  eye  being  had  to  tlic  situation  of  the  more  import- 
tant  vessels  and  nerves.  In  other  respects,  the  general  prin- 
ciples of  treatment  are  similar  to  those  of  incised  wounds. 
Opium  should  be  administered  largely ;  and,  if  much  ten- 
sion supervene,  or  matter  form,  free,  incisions  will  be  neces- 
sary. 

In  lacerated  idoh/uIs,  the  edges  should  be  tacked  together 
very  gently,  and  large  interspaces  left  for  drainage.  A 
small  portion  will  probably  unite  by  the  first  intention;  the 
remainder,  by  the  granulating  pvocess.  Such  wounds 
nearly  always  suppurate  more  or  less  profusely,  and  some 
of  the  torn  andbruisedtissues  not  unfrequently'perish.  The 
same  bad  consequences  arc  apt  to  follow  them  as  in  punc- 
tured wounds.  A\"arm  Avater  constitutes  the  best  dressing, 
either  alone  or  \vith  the  addition  of  a  little  spirits  of  camphor. 
Opium  should  be  used  freely  internally,  and  the  diet  must 
be  supporting. 

Gunshot  v-ound.^,  in  their  general  character,  partake  of 
the  nature  of  lacerated  and  contused  wounds.  They 
are,  of  course,  the  most  common  and  dangerous  lesions  met 
with  in  military  practice  ;  often  killing  insfantl}',  or,  at  all 
events,  so  mutilating  the  patient  as  to  destroy  Inm  within 
a  few  hours  or  days  after  their  receipt.  The  'most  formid- 
able wounds  of  the  kind  are  made  by  the  conical  rifie  and 
musket  balls  and  by  cannon  balls,  the  latter  often  carrying 
away  the  greater  portion  of  a  limb,  or  nuisliingand  pulpif}"- 
ing  the  muscles  and  viscera  in  the  most  frightful  and  des- 
tructive manner ;  while  the  former  commit  ten-iblo  ravages 


oO  Miltiari/  /S^^Y/ir//. 

amouir  tlie  bones,  broakius:  tlieni  into  numerous  fragments, 
each  of  wLich  may,  in  its  turn,  tear  up  the  soft  tissues,  in  :« 
way  perhaps  not  less  mischievous  than  the  ball  itself.  Tlir. 
old  round  ball  is  a  much  less  latal  weapon  tlian  the  conical, 
which  seldom  becomes  flattened,  and  Avhicli  Jias  been 
known  to  pass  throuirh  the  body  of  two  men  and  lod,jro  in 
that  of  a  third  some  distance  off. 

AVhen  a  ball  lodges,  it  makes  generaliy  only  one;  oriticc  : 
but  it  should  be  remembered  that  it  may  make  two,  three, 
and  even  four,  and  at  last  bury  itself  more  or  less  deeply. 
Should  the  missile  escape,  there  will  necessarily  be  two 
openings;  or,  if  it  meet  a  sharp  bone  and  be  thereby  di- 
vided or  cut  in  pieces,  as  sometimes  happens,  there  may  be 
even  three.  The  orifice  of  entrance  and  the  orifice  of  exit 
ditier  in  their  appearances.  The  first  is  small,  rouu<i,  and 
often  a  little  discolored  from  the  explosion  of  the  i)Owder : 
the  other,  on  the  contrary,  is  comparatively  large,  slit-like, 
everted,  and  free  from  color.  These  difterences,  however, 
are  frequently  very  trifling,  particularly  if  tlic  ball  l)e  pro- 
jected with  great  velocity  and  it  do  not  encounter  any  bone. 
The  opening  of  entrance  made  by  the  round  ball  is  often  a 
little  depressed  or  inverted,  but  such  an  appearance  is  ex- 
tremely uncommon  in  wounds  made  by  the  conical  ball. 

It  is  often  a  matter  of  great  importance  to  determine, 
when  two  openings  exist  in  a  limb,  wliether  they  have 
been  made  by  one  ball,  wliich  has  passed  out,  or  by  two 
balls,  which  are  retained.  The  question  is  of  grave  im- 
poi-tauce,  both  in  a  practical  and  in  a  medico-legal  i>oint  of 
view  :  but  its  solution  is,  unfortunately,  not  always  possible. 
Sometimes  the  openings  of  entrance  and  exit  are  nuiterially 
modified  by  the  introduction  but  non-escape  of  a  foreign 
body,  as  a  piece  of  brcast-])late,  belt  or  buckle,  along  witli 
the  "ball,  which  alone  passes  out,  or  by  the  flattening  of  a 
ball  against  a  bone,  or  its  division  by  a  bone  into  several 
fragments,  each  of  which  may  afterward  ]iroduce  a  separ- 
ate orifice.  Generally  speaking,  the  missile,  at  the  place  of 
entrance,  carriers  away  a  piece  of  skin,  and  rends  the  skin 
where  it  escapes,  the  former  being  often  found  in  tlu- 
wound. 

Bullets  sometimes  ghince,  bruising  the  nkin,  but  noi 
penetrating  it;  at  other  times  they  eiiect  an  entrance,  l)ut, 
instead  of  passing  on  in  a  straight  line,  are  deflected,  cours- 
ing, perhaps,  ])artially  round  the  head,  chest,  or  abdomen, 
or  round  a  limb.     Sucli  lesults  are  most  commonly  caused 


Jliliiari/  Sur(/e)\>/.  31 

by  a  partially  spent  bullet  coining  in  contact  "with  bones, 
aponeuroses,  and  tendons  ;  and  the  round  is  more  frequent- 
ly served  in  this  way  than  the  conical. 

Gunshot  wounds  bleed  profusely  only  when  a  tolerably 
large  artery  has  been  injured,  and  in  this  event  they  may 
speedily  prove  Mai.  During  the  Crimean  war,  however, 
many  cases  occurred  in  which  there  was  no  immediate 
liemorrhage,  imperiling  life,  notwithstanding  the  limbs, 
lower  as  well  as  upper,  Avere  left  hanging  merely  by  the  in- 
teguments. Under  such  circumstances,  mfenncdiavi/  hem- 
orrhage, as  it  is  termed,  is  apt  to  show  itself  as  soon  as 
reaction  takes  place  ;  generally  within  a  few  hours  after  the 
accident. 

The  pain  is  of  a  dull,  burning,  smarting,  6r  aching 
character,  and  the  patient  is  pale,  weak,  tremulous,  nauseat- 
o(\,  and  despondent,  often  in  a  degree  tar  beyond  what 
might  be  expected  from  the  apparent  violence  of  the  injury, 
and  that,  too,  perhaps,  Avhen  the  individual  is  of  the  most 
undaunted  courage  and  self-possession  in  the  heat  of  battle. 
At  other  times  a  man  may  have  a  limb  torn  olf^  or  be  in- 
jured in  some  vital  organ,  and  yet  hardly  experience  any 
shock  >vhatever ;  nay,  perhaps  be  scarcely  conscious  that  he 
is  seriously  hurt.  The  pain'  and  prostration  are  always 
greater,  other  things  being  equal,  when  a  bone  has  been 
crushed  or  a  large  joint  laid  open,  than  when  there  is  a  mere 
flesh  wound. 

The  gravity  of  gunshot  wounds  oH  the  Joints  has  been 
recognized  by  all  practitioners,  ])oth  military  and  civil, 
from  time  immemorial.  The  principal  circumstances  of 
tlie  prognosis  are  the  size  and  complexity  of  the  articulation, 
the  extent  of  the  injury,  and  the  state  of  the  system.  A 
gunshot  wound  of  a  ginglymoid  joint  is,  in  general,  a  more 
dangerous  atlair  than  a  similarone  of  a  ball-and-socket  joint. 
The  structures  around  the  articulation  often  suffer  severely, 
thus  adding  greatly  to  the  risk  of  limb  and  life.  Ofiif) 
cases  of  gunshot  wounds  of  diifercnt  joints,  related  by 
Alcock,  33  recovered  ;  but  of  these  21  lost  the  limb.  ()f 
the  32  that  died  no  operation  was  performed  upon  1§. 

Gunshot  wounds  of  the  smaller  joints,  even  those  of  the 
ankle,  often  do  very  well,  although  they  always  require 
long  and  careful  treatment.  Lesio'ns  of  tins  kind,  involving 
the  shoulder,  are  frequently  amenable  to  ordinary  means. 
If  the  ball  lodges  in  the  head  of  the  humerus,  it  must  be  ex- 
tracted without  delav,    it<>   retention    beina:  sure  to  excite 


MiUlar»f  Surfjcr}!. 

violent  inflaniination  in  the  sol't  parts,  and  caries  or  necro- 
sis in  the  l)one,  ultimately  necessitating  amputation,  if  not 
causino:  death. 

(-Junshot  wounds  ot  tlie  hncc-jo'ud  are  among  the  most 
dangerous  of  accidents,  and  no  attempt  should  he  made  to 
save  the  limh  when  the  injury  is  at  all  extensive,  especially 
if  it  involves  fracture  ofthe,liead  of  the  tibia  or  condyles  o^i 
the  femur.  Even  extensive  laceration  of  the  ligament  of 
the  patella  should,  I  think,  as  a  general  rule,  be  regarded  as 
a  sufficient  cause  of  amputation.  Tn  1854,  Macleod  saw  w^- 
wards  of  forty  cases  of  gunshot  wounds  of  the  knee  in  tlie 
French  hospitals  in  the  Crimea,  and  all,  except  one,  in 
which  an  attempt  was  made  to  save  the  limb,  proved  fatal. 
Of  nine  cases  which  occurred  in  India,  not  one  was  saved. 
Guthrie  never  saw  a  patient  recover  from  a  gunshot  wound 
of  the  knee-joint ;  and  Esmarch,  who  served  in  the  Sehles- 
wiir-IIolstein  wars,  expressly  declares  that  all  lesions  of  this 
kind  demand  immediate  amputation  of  the  thigh. 

AYhen,  in  bad  cases  of  these  articular  injuries,  an  attemj)t 
is  made  to  save  the  limb,  the  patient  often  perishes  within 
the  iirst  three  or  four  days,  from  the  conjoined  eitects  ul 
shock,  hemorrliage,  and  traumatic  fever.  If  he  survives  for 
any  length  of  time,  large  a])scesses  arc  apt  to  form  in  and 
aroundthe  ,joint,  the  matter  burrowing  extensively  among 
the  nmscles,  and  causing  detachment  of  the  periosteum  with 
caries  and  necrosis  of  the  bones. 

Mui>cles,  badly  injured  b}' bullets,  generally  suppurate,  and 
are  very  a} »t  to  become  pennanently  useless.  JSpecial  pains 
should  therefore  be  taken  to  countei-act  this  tendency  during 
the  cure.  Large  shot  and  other  foreign  bodies  sometimes 
lodge  among  these  structures,  wliere  their  ]n-esence  may  re- 
main for  a  long  time  unsuspected. 

Cannon  balls  often  do  innnense  nii&chief  by  striking  the 
surface  of  the  body  oblifjiiely,  ])ulpilying  the  soft  structures, 
cruihing  tlie  bones,  lacerating  the  large  vessels  and  nerves, 
and  tearing  open  tlio  joints,  with(tut,  perlia]»s,  materially  in- 
juring the  skin. 

A  very  terrihle  Ibiin  <>l'  co/iiu^-io/i  is  ot'len  intlicted  upon 
the  upper  extremity  of  artillerymen  by  the  premature  exjdo- 
sion  of  the  gun  while  in  the  act  of  loading  ;  causing  excessive 
commotion  of  the  entire  limb,  laceration  of  the  soil  parts, 
and  most  extensive  infiltration  of  blood,  accompanied,  in 
many  cases,  by  comminuted  fracture,  and  penetration  of  the 
wrist  and  elbow  joints.     Tlin  constitutional  shock  is  frerpient- 


Military  Sur^/crj/.  33 

\y  great.  If  an  attempt  be  made  to  save  tlie  parts,  difl'asivc 
suppuration,  and  more  or  less  gangrene,  will  be  sure  to  follow, 
bringing  life  into  imminent  jeol)ard3^  An  attempt  in  such  a 
case  to  save  the  limb  would  be  worse  than  useless,  if,  indeed, 
not  criminal ;  amputation  uiust  be  promptly  performed,  and 
that  ataconsideraldc  distance  above  the  apparent  seat  of  the 
injury,  otherwise  mortification  might  seize  u]>oii  the  stump. 

In  the  treatment  o\i  this  class  of  injuries,  the  lirst  thing  to 
be  done,  after  arresting  the  hemorrhage  and  relieving  shock, 
is  to  extract  the  ball  and  any  other  foreign  substance  that  may 
have  entered  along  with  it,  the  next  being  to  guard  against 
infiannnation  and  other  bad  consequences. 

In  order  to  ascertain  where  the  ball  is,  the  limb  should  be 
l)laced  as  nearly  as  possible  in  the  position  it  was  supposed  to 
have  been  at  the  nuimcnt  of  the  accident.  A  long,  stout, 
rtexible,  blunt-pointed  probe,  or  a  straight  silver  catheter,  is 
then  passed  along  tlie  track  and  gently  moved  about  until  it 
strikes  the  ball,  in  many  cases  the  best  probe  is  the  surgeon's 
finger.  Valuable  information  nuiy  often  l)c  obtained  by  the 
process  of  pinching  or  digital  compression,  the  ends  of  the  fin- 
gers being  firmly  and  regularly  pressed  against  the  wounded 
structures,  bones  as  well  as  muscles,  tendons,  and  aponeuroses. 
Occasionally,  again,  as  when  a  ball  is  lodged  in  an  extremity, 
its  presence  is  easily  detected  l)y  the  patient,  M'bo  may  make 
such  an  examination  as  he  lies  in  bc(h 

The  situation  of  the  foreign  body  having  been  ascertained, 
tlie  bullet-forceps  take  the  place  of  the  probe,  the  blades, 
which  should  be  long  und  slender,  being  closed  until  they 
come  in  contact  with  the  ball,  when  they  are  expanded  so  as 
to  grasp  it,  care  being  taken  not  to  include  any  of  the  soft 
tissues.  If  there  be  any  loose  or  detached  splintei-s  of  bone, 
wadding,  or  other  foreign  material,  it  should  now  also  be  re- 
moved ;  it  being  constantly  borne  in  inind  that,  while  a  ball 
may  occasionally  become  encysted,  and  is  at  all  times,  if 
smooth,  a  comparatively  harmless  tenant,  such  substances 
always  keep  up  irritation,  and  should,  therefore,  if  possible, 
be  got  rid  of  without  delay. 

Although  preference  is  commonly  given  to  the  bullet-for- 
ceps, properly  so  called,  as  an  extractor,  the  jiolypus  and  dres- 
sing-forceps, generally  answer  quite  as  well,  especially  the 
former,  the  latter  being  adapted  only  to  cases  where  the  for- 
eign body  is  situated  a  short  distance  below  the  surface,  or 
wliere  the  wound  is  of  unusual  dimensions,  admitting  of  the 
IVce  play  of  the  instrument. 

During  the  extraction,  the   ])arts  should  be  i>roperly  sup- 


-U  Militart^  ^'Surgcr/j. 

ported,  and  if  the  wound  is  not  large  enough  lor  the  expan- 
sion of  the  instrument,  it  must  he  t-uital)l_v  enlarged.  "When 
the  ball  is  lodged  u  .short  distance  from  the  f-kin,  it  may  often 
be  readily  reached  by  a  counter-opening. 

When  a  bullet  is  embedded  in  a  bone,  as  in  the  head  of  the 
tibia,  or  in  tiie  condyles  of  the  femur,  and  the  parts  are  not 
HO  much  injured  as  to  demand  am])utation,  extraction  may  be 
effected  witli  the  aid  of  the  trejdime  and  elevator.  Sometimes 
a  bullet-woi-m,  as  it  is  termed,  an  instrument  similar  to  that 
used  in  drawing  ji  Itall  frcnu  a  gun.  will  be  very  convenient 
lor  its  removal. 

The  operation  l^eing  completed,  the  ])arts  are  placed  in  an 
easy,  elevate(J  position,  and  cnveloi:)ed  in  tepid,  cool  or  cold 
■\vater-dressings,  as  may  be  most  agreeable  to  them  and  to  the 
system.  The  best  plan,  almost  always,  is  to  leave  the  opening 
or  openings,  made  by  the  liall,  free,  to  favor  drainage  and 
prevent  pain  and  tension.  If  the  track  be  very  narrow,  it 
may  heal  by  the  lirst  intention,  but  in  general  it  will  suppur- 
ate, and  portions  of  tissue  may  even  mortify.  Eiysipelas. 
pyemia,  and  secondary  hemorrhage  are  some  of  the  bad  con- 
sequences after  gunshot  injui-ies,  the  latter  usually  coming  on 
between  the  tiftii  and  nintli  day.  the  period  <»f  the  separation 
of  the  slouirhs. 


CHAPTER  VI. 

AMl'lTATIOXS    AND   KESECTIOX^ 


in  endeavoring  to  decide  so  important  a  (piestion  as  the 
loss  of  a  lind),  various  eircnmstances  are  to  be  considered,  as 
the  age,  habits  and  previous  health  of  the  patient,  the  kinds 
of  injury,  and  the  number,  nature,  and  importance  of  the  tis- 
sues involved.  In  military  practice  amputation  must  often 
be  performed  in  cases  Avhere  in  civil  practice  it  might  l>e 
avoided. 

It  may  l)e  assumed,  as  a  lule,  that  young  adults  bear  up 
under  severe  accidents  and  operations,  other  things  being 
»'(jnal, much  better  than  children  and  elderly  subjects;  the 
strong  than  the  feeble ;  the  temperate  than  the  intemperate; 
the  residents  of  the  counti-y  tiuin  the  iidiabitants  of  the 
crowded  city. 

The  following  circumstances  may  be  enumerated  as  justify- 
ing, if  not  imperatively  demanding,  amputation  in  cases  of 
wounds,  whatever  mav  be  their  nature  : 


MiliOini  Surf/cri/. 

1st.  When  a  limb  has  been  struck  by  a  caunon  ball  or  run 
over  by  a  railroad  car.  fracturing  tho  bones,  and  tearing  o)5en 
the  soft  parts,  amputation  should,  as  a  general  rule,  be  per- 
formed, even  when  the  injury  done  to  the  skin  and  vessels  i.s 
apparently  very  slight,  experience  having  shown  that  snch 
accidents  seldom  do  well,  if  an  attempt  is  made  to  save  the 
limb,  the  patient  soon  dying  of  gangrene,  pyemia,  or  typhoid 
irritation.  The  danger  of  an  uufavorable  termination  in  such 
a  case  is  always  greater  when  the  lesion  affects  the  lower  ox- 
tvemity  than  when  it  involves  the  superior. 

•2d.  Ko  attempt  should  be  made  to  save  a  limb  when,  in 
addition  to  serious  injury  done  to  the  integuments,  nmsclesor 
bones,  its  principal  artery,  vein  or  nerve  has  been  extensively 
lacerated,  or  vioiently  contused,  as  the  result  will  be  likely  to 
be  gangrene,  followed  by  death.  ' 

3d.  A  lacerated  or  gunshot  wound  penetrating  a  large  joint, 
aK  that  of  the  knee  or  ankle,  and  accompanied  by  comminu- 
ted fracture,  or  extensive  laceration  of  the  ligaments  of  the 
articulation,  will,  if  left  to  itsell',  be  very  prone  to  terminate 
in  mortification,  and  is  therefore  a  proper  case  for  early  am- 
putation. 

4th.  Gunshot  wounds  attended  with  severe  connninution  of 
the  bones,  the  fragments  being  sent  Avidely  around  among  the 
soft  parts,  lacerating  and  bruising  them  severely,  generally 
require  amputation,  especially  in  naval  and  military  practice. 

5th.  Extensive  laceration,  contusion,  and  stripping  off  of 
the  integuments,  conjoined  with  fracture,  dislocation,  or  com- 
pression and  pulpitication  of  the  muscles,  will,  in  general,  be 
a  proper  cause  for  the  removal  of  a  limb.'"' 

Amputation  is  not  to  be  performed,  in  any  case,  until  suth- 
eient  reaction  has  taken  place  to  enable  the  patient  to  bear 
I  he  additional  shock  and  loss  of  blood.  As  long  as  he  is  dead- 
ly pale,  the  pulse  small  and  thready,  the  surtace  cold,  and  the 
thirst,  restlessness,  and  jactitation  excessive,  it  is  obvious  that 
recourse  to  the  knife  must  l)e  wliolh'  out  of  the  question. — 
The  proper  treatment  is  recimibency,  with  mild  stimulants, 
sinapisms  to  the  extremities,  and  other  means  calculated  to 
re-excite  the  action  of  the  heart  and  brain.  Power  being  re- 
stored, the  operation,  if  deemed  necessary,  is  proceeded  yvith, 
due  regard  being  had  to  the  prevention  of  shock  and  hemorr- 
hage, the  two  things  now  mainly  to  be  dreaded. 

One  of  the  great  obstacles  about  immediate  amptitatiou  is 
the  difficulty  which  the  surgeon  so  often  experiences  in  res- 

*Girosrt'  Surgery,  vol.  i.  p.  395. 


•5'>  Miidary  Si(rfjm/. 

pect  to  the  cases  doiniiiidiniL!:  tlie  operation,  and  tlic uncertain- 
ty that  none  of  tlic  internal  organs  liave  sustained  fatal  in- 
jnry;  a  circumstance  wliich  wouhl,  of  courj^e,  contra-indicatc 
the  propriety  of  such  interference. 

Cases  occur,  although  rarely,  Avhere,  notwithstanding  the 
most  violent  injury,  or  ])erhaps,  even  the  loss  of  a  limb,  there 
is  hardly  any  a]>precial)lc  shock,  and,  in  such  an  event,  the 
operation  sliould  hi'  performed  on  the  s])ot. 

The  results  of  the  military  surgery  in  the  Crimea  show  tliat 
the  success  of  amputations  was  very  fair  Avhen  performed  ear- 
ly, but  most  unibrtunate  Avhen  they  were  put  oft' for  any  length 
<»f  time.  This  was  the  case,  it  "would  seem,  both  in  the 
English  and  French  armies. 

Should  amputation  ever  be  performed  in  s])reading  gan- 
gi'ene  (  The  answer  to  this  question  must  depend  upon  cir- 
cuuistances.  We  may  give  our  sanction  wheji  the  disease, 
although  rapid,  is  still  limited,  and  when  the  patient,  compar- 
atively stout  and  robust,  has  a  good  pulse,  with  no  serious 
lesion  of  a  vital  organ  and  no  despair  of  his  recovery,  but  a 
cheerful,  l)Uoyant  mind,  hopeful  of  a  favorable  issue.  Xo  op- 
eration is  to  be  done  when  the  reverse  is  the  case;  if  it  be,  tlie 
patient  will  cither  perish  on  the  table,  from  shock  and  hem- 
orrhage, or  from  a  recurrence  of  mortification  in  the  stump. 

Lacerated,  contused,  and  gunshot  wounds  are  often  of  so 
frightful  a  nature  as  to  render  it  perfectly  certain,  even  at  a 
glance,  that  the  limb  will  be  obliged  to  be  sacrificed  in  order 
that  abetter  chance  maybe  afforded  for  preserving  the  pa- 
tient's life.  At  other  times,  the  injury,  although  severe,  may 
yet,  apparently,  not  be  so  desperate  as  to  preclude,  in  the 
opinion  of  the  practitioner,  the  ])ossibility  of  saving  the  parts, 
or  at  all  events,  the  propriety  of  making  an  attempt  to  that 
effect.  The  cases  wliich  may  reasonably  require  and  those 
which  may  not  require  interference  witii  the  knife  are  not 
always  so  clearly  and  distinctly  defined  as  not  to  give  rise,  in 
very  many  instances,  to  the  most  serious  and  unpleasant  ap- 
])rehension,  lest  we  should  be  guilty,  on  the  one  hand,  of  the 
sin  of  commission,  and,  on  the  other,  of  that  of  omission ;  or, 
in  other,  and  more  comprehensive  terms,  that  while  the  sur- 
geon endeavors  to  avoid  Scylla,  he  nuiy  not  unwittingly  run 
into  Charybdis,  mutilating  a  limb  that  might  have  been  saved, 
and  endangering  life  by  tlie  retention  of  one  that  should  have 
been  promptly  amputated.  It  is  not  every  man,  however 
large  his  skill  and  experience,  that  is  always  able  to  satisfy 
himself,  even  after  the  most  ])rofound  delil)eration,  what  line 
of  coiidnct  shonld  bo  ])nrsued  in  these  trying  circnmstanccs  ; 


Militani  Sarj/cr//.  '■*7 


■^-k.' 


lieuce  the  safest  plan  for  Iiira  generally  is  to  ])rocure  tlu.'  best 
counsel  that  the  emergencies  of  tlic  ease  may  admit  of.  r.ut 
in  doing  this,  he  mustbc  careful  to  guard  against  procrastinU- 
tion  ;  the  case  must  be  met  promptly  and  courageously  ;  de- 
lay even  of  a  few  hours  may  be  fatal,  or  at  all  events,  placr 
limb  and  life  in  innninent  Jeopardy.  Above  all,  let  proper 
caution  be  used  if  the  patient  is  obliged  to  be  transi)orted  to 
some  hoepital,  or  to  a  distant  home,  that  he  ina}"  not  be  »u1»- 
jected  to  unnecessary  pain,  exposed  to  loss  of  blood,  or 
carried  in  a  position  incompatible  -with  his  exhausted  condi 
tion.  A'ast  injury  is  often  done  in  this  way,  by  ignorant  per- 
!5ons  having  charge  <»f  the  case,  and  ttccasionally  even  by 
])ractitioners  whose  education  and  common  sense  should  be  n 
sufficient  guarantee  against  such  conduct. 

Little  need  be  said  here  about  the ///,c^//w/v  of  amputation. 
In  cases  of  emergency,  where  time  is  precious,  and  the  num- 
]»erof  snrgeous  inadequate,  the  flap  operation  deserves,  in  my 
opinion,  a  decided  preference  over  the  circular,  and.  in  fact. 
I'vury  other.  The  rapidity  with  which  it  may  be  executed, 
the  abundant  covering  which  it  aifords  for  the  bone,  an<l  the 
iacility  with  which  the  ])arts  unite  are  <|ualities  which  strong- 
ly recommend  it  to  the  judgment  of  the  military  surgeon. 
The  flaps  should  be  long  and  well  shaped,  and  car^  taken  to 
cut  ofl' the  larger  nerves  on  a  level  Avitli  the  l)onc,  in  order  to 
guard  against  the  occurrence  of  neuralgia  after  the  wound  is 
healed.  "Whatever  method  be  adopted,  a  long  stump  shouhl 
be  aimed  at,  that  itnuiy  aiford  a  good  leverage  for  the  artili- 
ial  substitute.  Xo  Idood  should  be  lost  during  or  after  ihe 
operation,  and  hence  the  main  artery  of  the  limb  should 
always  be  thoroughly  compressed  by  a  tourniquet,  not  by  the 
lingers  of  assistants.  \\ho  are  seldom,  if  ever,  trustM'orthy  on 
such  occasions. 

Awrfit  lie  firs  should  l)e  given  only  in  the  event  of  tliorougii 
reaction  ;  so  long  as  the  vital  powers  are  depressed  and  the 
mind  is  bewildered  by  shock,  or  loss  of  blood,  their  adminis- 
tration will  hardly  be  safe,  unless  the  greatest  vigilance  bi.' 
employed,  and  this  is  not  always  possible  on  the  iield  of  liat- 
tle,  or  even  in  the  hospital.  ]\ioreover,  it  is«stonishing  what 
little  sutfering  the  patient  generally  experiences,  when  in  this 
condition,  even  from  a  severe  wound  or  operation. 

Ln  the  war  in  the  Crimea,  the  Ih'itisb  used  chloroform  id- 
most  univei'sally  in  their  oj^erations;  the  French  also  exhibi- 
ted it  very  extensively,  (md  Uaudens,  one  of  their  lea<Ung 
niilitar}' surgical  authorities,  declares  that  they  did  not.  meer 
with  one   fat;d  accident  from   it,   ;dtlK>n!ih  it.   was  li'iven    bv 


:').s  MiUlavji  -Sarfji'n/. 

tlicm,  durini;'  the  Eastern  campaign,  thirty  tliousand  times  at 
least.  The  sidinhiititration  ot'chhirotbrm  is  stated  by  Macleod 
10  have  euntrihntcd  iniimiisely  fo  the  success  of  iirimnry  am- 
putation.-. 

The  drci'siiKjii  ^iiould  Ije  api)lied  aceording  to  the  priiu-iples 
laid  d<»^vn  under  the  head  <»1'  wuund:^.  The  sutures,  made 
with  bilvcr  wire  <>r  line  silk,  should  not  be  too  numerous,  and 
the  adheriive  t<trips  mnst  be  so  arranged  as  to  admit  of  thor- 
ough drainage.  A  bandage  should  bo  applied  from  above 
d(j\vnAvard.  to  <'outrul  muscnlar  action  and  atiord  support  t<> 
iheve.sscls:  the  btuuip  re.st  upon  a  pillow  covered  with  oil- 
cloth, and  the  water-dressing  be  used  if  there  is  danger  of 
overaction.  Pain  and  spasm  are  allayed  by  anodynes  ;  trau- 
matic fever,  by  mild  diaphoretics.  Copious  purging  is  avoid- 
ed; the  drinkis  cooling;  and  the  diet  must  be  in  strict  confor- 
mity with  the  condition  of  the  patient's  system.  The  first 
dressings  are  removed  about  the  end  of  the  third  day  ;  after 
ihat  once  nj-  even  twice  a  day,  according  to  the  nature  and 
ijuautity  uf  the  discharges,  accumulation  and  bagging  V>i>ing 
faithfully  guaixled  against. 

The  following  statistics  <>f  amputations,  both  in  the  contin- 
uity of  tlu;  limbs  and  of  the  articulations,  possesses  peculiar 
interest  fui;, the  military  surijeon.  They  are  derived  chie-fly 
in  mi  a  review  which  1  published  «jf  ]\Ir.  Macieod's  ''Notes  of 
the  Surgery  in  the  Crimea,"  in  the  North  American  ^Fedico- 
('hirurgical  llevicw  for  January,  ISUO. 

The  number  of  cases  given  by  Macleod  is  732,  with  a  nutr- 
tality  of  201.  Of  these,'  054  Merc  primary,  with  165  deaths, 
ui-  \tiW2i  per  cent.;  and  7S  secondary,  with  yO  deaths,  or  in  the 
i-atioof  -f(M.  The  mortality  of  the  greater  amputations — a< 
those  of  the  shoulder,  arm,  and  forearm,  and  the  hi}),  thigh, 
knee,  and  leg — was  IJO-S  per  cent,  for  the  prinniry  oi)erations, 
and  00  per  cent,  for  the  secondary. 

The  increase  of  mortality  from  amputations  as  M-e  tipi)roach 
the  trunk,  has  long  been  familiar  to  surgeons,  and  the  results 
in  the  Crimea  have  Jiot  changed  our  previous  knowledge. 
Thus  the  ratio  of  mortality  of  amputations  of  the  lingers  was 
(t-o  :  of  the  for(j^irm  and  wrist,  I'S ;  of  the  arm,  22-9;  of  the 
shoulder,  27-2;  of  the  tarsus,  14*2;  of  the  ankle-joint,  22-2; 
of  the  leg,  SO'o;  of  the  knee-joint,  50-0;  of  the  thigh,  in  iis 
lower  third,  50-0,  at  its  middle,  55-o,  at  the  upper  part,  SO'S, 
and  at  the  hip,  lOO'O.  The  lind)  was  removed  at  the  latter 
joint  in  101  cases,  all  of  whicli  rapidly  proved  iatal.  Tlu- 
French  had  V^  eases.  ]>ri)narv  and  secondarv,  with  no  better 
luck. 


Mil'dat\ij  Sanjci;!.  3*> 

Lcgoiiest  litis  piiblislied  a  table  of  most  of  the  recorded 
cases  of  amputation  at  the  hip-joiai ,  for  o-nusliot  wouiuls.  ()t' 
these  SO  were  primary,  and  all  ended  iatally ;  of  1 1  interine- 
<liatc,  or  early  secondary,  o  recovered ;  and  of  o  remote,  1  re- 
covered, "Thus,"  says Maclcod,  "if  avc  sum  up  the  whole, 
AVC  have  V  recoveries  in  44  cases,  or  a  mortality  of  OO-I)  per 
cent."'  Some  of  the  primary  cases  ch'ed  on  (In?  table;  and 
all  the  rest,  except  two,  l)efore  the  tenth  day.  Jii  the  Schlcs- 
wig-IIolstein  war,  amputation  at  the  hip  joint  was  performed 
seven  times,  "with  one  cure.  Mr.  iSands  Cox,  recording  the 
experience  of  civil  and  military  hospitals  up  to  1840,  giVes84 
cases,  most  of  them  for  injury,  with  2G  rec<tverics.  Dr. 
Stephen  Smith,  of  Kew  York,  has  published  tables  of  08  cases 
showing  a  ratio  of  mortality  of  1  in  2  2-o.  In  <>3  of  these 
cases,  the  o])eration  was  perl'oi-med  in  .'Vi  for  injni-y.  with  a 
mortality  of  60  per  cent. 

Amputation  in  the  upper  thii-d  of  the  ih'tfjh  was  performed 
;}0  times,  with  a  fatal  result  in  o\.  Uf  these  cases  only  oiu> 
was  secondary,  and  that  perished.  Amputation  of  the  mid- 
dle third  of  the  limb  was  })erformed  in  i)o  cases,  of  which  SS 
died.  Of  these  cases  5<)  Averc  ])rinuiry,  with  'Al  deaths,  giving 
thus  a  mortality  of  o3-S  per  cent.;  {>  cases  were  operated  upon 
at  a  later  period,  and  of  these,  7  died,  or  77*7  per  cent.  Am- 
putation of  the  lower  third  of  the  thigh  was  peiformed  (5»> 
times,  4G  being  ])rimary,  with  a  mortality  of  50  per  cent.,  and 
14  secondary,  with  a  mortality  of  71'4  per  cent. 

Amputation  at  the  l.-ncc  was  performed  ])rimarilyiu  <1  cases 
of  which  ?>  died,  and  once  secondarily,  witli  a  fatal  resnU. 
Chelius  refers  to  37  cases  of  amputation  of  the  knee,  collected 
by  Ja'gcr,  of  which  22  were  favorable  ;  antl  of  18  cases  i-e- 
corded  by  Dr.  Markoe,  of  jS'ew  York,  as  having  occurred  in 
the  practice  of  American  surgeons,  13  got  well.  These  cases 
added  together,  aiford  an  aggregate  r.f ""(;!.  M-ith  a  inort.olitN 
of  21,  or  34-4  per  cent. 

The  lv(/  was  amputated  101  times,  with  30  deaths,  ..ra  mor- 
tality of  35-()  per  cent.  Of  these  cases  80  were  ]»rimai\. 
with  2S  deaths,  and  12  secondary,  Avitli  S  d(>aths. 

Amputation  at  the  anUe-joint  was  peribrmed  in  12  eases, 
death  following  in  2.  Of  these  cases  3  were  secondarv.  and 
all  favorable. 

The  arm  Avas  removed  at  tiie  f<hould<r  joint  in  30  ca-^i's. 
with  a  fatal  issue  in  13,  or  33-3  per  cent,  33  being  primarv. 
with  0  deaths,  and  G  secondary,  with  a  tatal  issue  in  4.  if  we 
couple  these  cases  with  21  that  occurred  during  the  previous 
period  of  the  war,  we  shall  have  an  aggregate  of  {10  case.-, 
with  19  deaths,  ova  mortality  of  ,31.0  per  cent.     The  advan- 


4  ( •  Miliiarif  iSurgi^y. 

tage  of  primaiy  over  secondary  amputation  of  the  Bhouldor 
has  long  been  known  to  military  surgeons.  Thus,  of  10  pri- 
mary cases  mentioned  by  Mr.  Guthrie  as  havin^^  occurred  be- 
tween June  and  September,  ISI'3,  IS  recovered,  while  of  1!» 
secondary  cases,  15  died.  The  experience  of  the  late  Dr. 
Tiiomson,  in  I>elgium,  is  equally  decisive. 

Amputation  of  the  upper  ai-m.  was  perlormcd  lOii  time^. 
with  death  in  "25  cases,  or  a  mortality  of  2A'o  ;  OG  of  the  cases 
l»eing  primary.     Of  the  secojidary  cases  one-half  proved  fatal, 

Tho /orecd'tih  was  amiiutated  Y)rimarily  52  times,  and  the 
hand  at  the  wrist  once,  with  only  1  death ;  while  of  7  second- 
ary operations  upon  the  same  parts,  '2  died. 

Resection  is  one  of  the  aids  of  conservative  surgery,  and 
inilitary  practice  affords  numerous  occasions  ibr  its  employ- 
ment. The  operatitm.  however,  is  not  eoually  applicable  lo 
all  the  articu  hit  ions.  Jlesoction  ol'  the  i<hoiddei'-joini  has 
hitherto  alibrded  the  most  ilattering  results.  It  is  more  es- 
pecially applical)le  in  cases  of  gunshot  injuries,  unattended 
by  serious  lesion  of  the  vessels  and  nerves  of  the  limb,  or  se- 
vere laceration  of  the  muscles  and  integuments.  A  portion 
of  the  humerus,  embracing,  if  necessary,  from  four  to  five 
inches  in  length,  together  with  a  part  or  even  the  whole  of 
the  glenoid  cavity  of  the  scapula,  may  be  safely  and  expe- 
ditiously removed  under  such  circumstances,  and  yet  the  ])a- 
tlcnt  have  an  excellent  use  of  his  arm. 

AVilliams  mentions  11)  cases  of  gunshot  wounds  of  tlie 
-houlder-joint  in  M'hich  resection  was  performed,  and  of  which 
;.'  proved  fatal.  l)audens  saved  13  out  of  14  cases,  and  the 
Ih-itish  surgeons  in  the  Crimea  lost  2  patients  out  of  27. 

Jlesection  of  the  elho^n  has  of  late  engaged  much  attention 
among  military  men,  and  although  the  results  are  less  Ilatter- 
ing than  in  the  operation  upon  the  shoulder,  they  are,  never- 
theless, highly  encouraging.  Of  82  cases  which  occurred  in 
the  Schleswig-llolsteinand  in  the  Crimean  campaigns,  only 
1(!  died,  or  1  in  about  5. 

The  ?/;m/;/o???/ has  seldom  been  the  subject  of  excision ; 
doubtless,  cases  not  unfrequently  occur  in  which  it  might  !)e 
resorted  to  with  advantage. 

Dr.  George  AVilliams  has  collected  the  history  of  11  cases 
<'f  excision  of  the  hvp-jornt  for  gunshot  injury,  (>  of  which  oc- 
curred in  the  Crimea, '  Of  this'nund>er  10  died.  Of  23  am- 
])nt,ations  at  the  hip  joint  by  the  Knglishand  French  surgeons 
in  the  Eaat;  all  died. 

Excision  of  the  lv2t'c';/()/??n'or  gunshot  injury  holds  out  no 
|irospecl  ol'  nd vantage.  ex]ierienco  having  shown    that,  when 


the  articulating  extremities  of  the  femur  and  tibia  aro  frac- 
tured by  a  ball,  the  proper  remedy  is  amputation. 

The  cmWt'-j'omz!  has  been  resected  in  a  few  instances  only 
ibr  gunshot  injuries,  and  the  results  have  thus  far  been  by  liu 
means  flattering.  ANHieii  the  joint  is  seriously  implicated,  am- 
putation-will  undoubtedly  be  the  more  Judicious   jirocedure. 

Resection  of  the  bones  in  their  continuity  is  seldom  prac- 
ticed in  this  class  of  injuries,  and  experience  has  offered 
nothing  in  its  favor.  The  operation  Avas  ])erlV>rmed  several 
times  in  the  Crimea,  but  proved  invariably  fatal. 

The  after-treatment  in  resection  must  be  conducted  upon 
the  same  principles  !is  in  am[>utation.  Tiie  measures  must, 
for  the  most  part,  be  of  a  corroborating  Tiature.  The  liniK 
must  be  ]daced  in  an  easy  position,  and  be  well  supported  l)y 
a  splint  or  fracture-box,  to  prevent  motion.  The  operation  is 
liable  to  be  followed  by  the  same  bad  elfccts  as  amputations. 


CIIAPTER  VII. 

HJ.   CONSJXirEXCKS    OF   "WOUNDS   AXD    Ol'KJ{ATIUX.-. 

The  bad  consequences  to  bo  apprehended  after  wounds, 
amputations,  and  other  operations,  are  traumatic  fever,  hem- 
orrhage, excessive  suppuration,  spasms,  erysipelas,  gangrene. 
}>yemia,  and  tetanus. 

a.  Trmimati(' fever  w^wnWy  sets  in  within  tlie  lirs.t  few  huurs 
after  the  injury,  or  soon  after  reaction  hns  been  fairly  estab- 
lished. In  camp  practice  its  tendency  generally  is  to  assunu' 
a  low  typhoid  character,  especially  if  there  is  much  crowding 
of  the  sick,  with  imperfect  ventilation  and  want  of  cleanliness. 
Xot  unfrecjuently  it  displays  an  endemic  or  epidemic  dispo- 
sition. 

The  treatment  must  be  exceedino-ly  mild;  ihe  patient  will 
not  bear  depletion,  but  will  notwithstanding  his  fever,  ])roba- 
bly  require  stimulants  and  tonics,  with  nutritious  focxl  and 
drink  from  tlie  very  commencement.  A  gentle  anodyne  and 
diaphoretic  mixture,  as  morphia  and  antimony  in  camphor- 
water,  may  be  needful,  in  the  early  stage,  to  quell  the  ficti- 
cious excitement  or  attempt  at  overaction. 

h.  The  likelihood  of  secondarij  hemorrhcujc  Jiiust  be  steatii- 
ly  kept  in  view  in  these  cases  ;  much  may  be  done  to  prevent 
it  by  the  proper  use  of  the  ligature  at  the  time  of  the  opei-a- 
vion  or  dressing,  but  it  is  often  unavoidable,  especially  in  gun- 
.-hot  wounds,  owing  to  the  injury  sustained  by  the  coats  of  the 
vessels  by  the  grazing  of  the   ball.     However  induced,  if 


sbould  roccivL-  llic  most,  prompt  attention,  inasiuuch  as  the 
loss  ovon  of  a  tow  ounces  of  blood  may  prove  destructive  t<> 
llic  already  exhausted  system. 

<■.  Sjxisms  of  the  nuisclc.s  is  ntit  peculiar  to  amputatioUc;  ; 
i I  often  cxistii  in  a  most  severe  degree  in  cases  of  fractures 
and  . aim  shot  wounds.  Anodynes  in  full  doses,  -vvith  a  little 
MUtimouy.  the  use  of  a  moderately-tight  bandage,  and  Avarm 
Mater-dressing,  medicated  Avith  laudanum  and  acetate  of  lead, 
are  the  most  appropriate  measures. 

'/.  Profane  sappurat ion.  may  be  looked  for  in  nearly  all  bad 
wounds,  whatever  their  character,  and  also  in  many  of  the 
.imputations  performed  on  the  held  of  battle.  The  exhaust- 
ing cifects  n)ust  be  counteracted  by  supporting  remedies,  as 
<|uinine,  iron,  cod-liver  oil,  and  brandy,  with  frequent  change 
of  <lressing,  cleanliness,  and  ventilation.  Bagging  is  }>re- 
\ mted  by  counter-openings  and  careful  ])andaging. 

(.  Ert/aijxUis  usually  manifests  itself  within  the  tirst  thirty- 
>ix  hours  after  the  injury  or  operation  ;  often  assumes  an  en- 
demic or  epidemic  character ;  is  easily  distinguislied  by  the 
])cculiar  reddish  blush  rapidly  sjircading  over  the  surface,  to- 
gether with  the  stinging  or  smarting  pain  and  increased  swel- 
ling; and  should  be  treated  with  dilute  tincture  of  iodine, 
'•r  anodyne  and  saturnine  lotions,  (juinine  and  tincture  of  iron, 
with  nutritious  food  and  drinks. 

f.  Ganr/rcric  is  sufficiently  common  after  severe  lesions  oji 
the  battle-field,  especially  that  variety  of  it  denominated  hos- 
pital gangrene.  ]")nring  the  Crimean  Avar,  this  form  of  gan- 
grene raged  with  extraordinary  virulence  und  fatality  among 
the  French  in  the  hospitals  on  the  EospUorus.  It  also  pre- 
vailed about  the  same  period  within  some  of  the  hospitals  in 
the  south  of  France,  and  it  is  asserted  that  the  "Euplirate,*'  a 
transport  ship,  in  her  voyage  to  the  ]\[editterranean  was 
obliged,  from  this  cause  alone,  to  throw  sixty  of  her  men  ovcr- 
Ijoard  within  thirty-six  hours!  After  the  taking  of  the 
Quarries  and  the  assault  upon  the  Redan,  during  the  heat  of 
summer,  in  IS.'S.Athe  English  surgeons  lost  a  number  of  their 
cases  of  amputation  of  the  thigh  from  moist  gangrene  of  a 
most  rapid  character,  the  system  having  been  literally  over- 
whelmed by  the  poison.  AVhcn  hospital  gangrene  is  endemic, 
it  attacks  not  oidy  open  wounds  and  sores,  but  also  the  slight- 
(•st  scratches,  cicatrices,  and  stumps.  Persons  laboring  under 
diarrha-a,  dysentery,  and  scurvy  are  most  obnoxious  to  it. 

The  pro))er  remedies  are  sc<piestration  c>f  the  patients,  the 
[\\'\}.  use  of  the  nitric  acid  lotion,  iodine  to  the  inliamcd  skin, 
c]iarei)al,  port  wine,  or  yeast  cataplasms,  and  frequent  ablu- 


M'ditar>j  Surt^eiy.  -to 

tions  with  disintecthig- fluids,  aided  l»y  opium,  qulniiu-.  tiiic- 
lurc  of  iron,  Icinon-jnice,  and  other  supporting  means.  Moj>- 
ping  the  affected  surface  ireely  witli  strong  nitric  acid  often 
ansWersan  excellent  purpose.  Tlie  favorite  renie<ly  of  ]*oii- 
teau  was  the  actual  cauterv, 

//.  Pycmda,  the  purulent  infection  of  tile  IVench  writers.  i> 
OHO  of  the  chief  dangers  after  severe  wounds  and  operations. 
It  was  tlie  great  source  of  the  mortality  after  amputations,  es- 
])ecially  secondary,  during  tlie  war  in  the  Crimea.  It  usually 
conies  on  AvithiniVom  tliree  to  eigiit  days  after  the  injury,  and 
is  nearly  always  fatal.  Its  characteristic  symptoms  arc  rigor.-. 
Ibllowed  hy  copious  sweats,  rapid  failure  of  the  \ital  powers, 
delirium,  and  a  withered  appearance  of  the  countenance,  U'^^- 
(piently  conjoined  with  an  ictorode  tinge  of  the  eye  and  skin. 
On  dissection,  the  largo  veins  leading  from  the  stump  nr 
wound  are  found  tilled  witli  ])us,  with  redness  of  the  lining 
uienibranc  ;  and  abscesses,  usually  small  and  tilled  with  un- 
iiealthy  fluid,  are  seen  scattered  through  the  lungs,  muscles. 
and  cellular  substance,  matter  also  occasionally  existing  in  Iho 
joints.  The  treatment  is  essentially  the  same  as  in  erysipelas. 

//.  Trauhiatlcirtanus  is  not  very  common  in  military  prac- 
lice.  It  is  most  liable  to  show  itself  in  tropical  countries,  in 
hot,  damp  weather,  and  in  persons  of  a  nervous,  irritable  tem- 
perament, occasionally  supervening  upon  the  most  insigniti- 
cant  injuries,  as,  for  example,  a  mere  scratch.  In  India  tbc 
ib'sease  is  often  provoked  by  uuextracted  balls,  and  l>oth  in 
that  country  and  on  the  continent  of  Europe  the  (»]?eration 
which  was  most  frecjuently  followed  by  it  during  tlic  recent 
wars,  was  amputation  at  the  shoulder-joint. 

The  cftccts  of  sudden  vicissitudes  of  tem],»eratnic  in  ilcvrl- 
oping  tetanus,  are  well  known.  Tiiey  are  most  striking  in 
tropical  regions,  M-lien  the  change  is  from  hot  to  cold,  or  from 
dry  to  wet.  Larrcy  had  repeated  opi)ortunities  of  observing 
the  development  of  the  disease  under  such  circumstances, 
i)Otli  in  Egypt  and  German}-.  After  tho  battle  of  l>antzen, 
the  exposure  of  the  wounded  to  the  cold  night  air  produced 
over  a  linmlred  cases  of  tetanus,  and  a  large  number  suffere<l 
from  a  si  mi  bar  cause  after  tlie  battle  of  Dresden.  Like  ef- 
fects were  witnessed  at  Eerozepore  and  Chilliamvallalf.  15an- 
dens,  in  his  treaties  on  gunshot  wounds,  states  that  the  in- 
fluence of  cold  and  moisture  in  developing  the  disease,  during 
the  Erench  campaigns  in  Africa,  was  most  striking.  Of  forty 
slightly  wounded  men,  placed  in  a  gallery  on  the  ground 
floor,  during  the  prevalcnco  of  a  northeasterly  wind,  flfteen 
were  speedily  nttacked  witli   tetanus.     Similai-  etlects   havr 


44  Milihinf  Stm/eiuf. 

-^cvcral  tinus  been  nuticod  i)i  this  oountrv.  Thuf>,  after  the 
Iiattlc  of  Tieonderoga,  in  1758,  nine  of  tlic  wounded  mIio 
were  t.'X))0sed  the  mIioIc  night  after  tlie  action,  in  open  Ixiuts 
npou  Lake  Oeorue.  died  of  loek-jaw  ;  and  durinii'  our  Avar 
with  (ire.ut  JJriiain,  most  of  those  wlio  sull'ered  on  hoard  the 
Aniiizon,  ill  the  enj^agenient  hefore  Cliark'st<.m,  were  attacked 
Avitli  this  disease  a  fortnight  after,  in  consequence  of  u  verv 
hudden  change  of  weather,  tlje  wind  Idowingcohl  and  wet. 

Tlie  extremes  of  heat  and  cohl  hotli  favor  the  production 
'■'f  tetanus.  In  the  East  and  West  Indies,  the  shghtcst  prick 
of  the  linger  or  too  i.'^  often  .suflicient  to  induce  the  disease, 
and  the  inhabitants  of  the  Arctic  regions  not  unfrcqucntly 
(Suffer  in  a  similar  mannej-.  Dr.  Kane,  in  ]iis  mcmorabk^  ex- 
pedition, k^st  two  of  his  men  from  tins  affection,  and  he  adds 
iliat  all  his  dogs  perished  from  a  like  cause. 

Tlio  mortulitji  from  traumatic  tetanus  is  notorious.  liardlv 
one  rccoveis.  Nearly  all  i)cri«.h  in  two  or  three  days  from  the 
attack. 

The  mo»t  reliable  remedies  are  opium,  in  the  form  of  mor- 
[>hia  or  acetated  tincture,  in  large  doses,  in  nnion  with  cam- 
plior  and  antimony.  The  effects  of  Indian  liemp  are  uncer- 
tain. Chloroform  will  mitigate  pain  and  spasms.  Amputa- 
lioii,  except,  perhaps,  when  the  wound  affects  a  finger  or  toe, 
will  l>c  worse  than  useless,  as  will  also  be  counter-irrita- 
lion  along  the  spine.  To  jirevent  the  disease  should  be 
our  business,  and  to  do  tliis  no  wounded  person  should 
ever  ])e  exposed  to  the  ct>hl  night  air,  or  to  currents  of 
air  at  any  time.  After  all  ic/nputailons,  however  trifuKj^ 
ypcciaJ  cllrecttons  fdiould  Ije  gwen  upon  this  point. 


CHAPTKK  VIIL 

iN.)i;uii;s  or  tjik  jie.M),  cjikst,  axji  auijomen. 
The  immediate  effects  oi  concumon  of  the  brain  are  those 
of  lainting  or  collapse,  and  must  be  treated  accordingly ;  by 
recumbency,  access  of  cold  air,  theui^e  of  the  Ian,  dashing 
oteohl  water  upon  the  lace  and  clicst,  and  sinapisms  to  the 
])recordial  region,  thighs,  ieet,  and  spine,  aided,  in  the  more 
severe  cases,'by  stimulating  injections.  If  the  patient  can 
swallow,  he  may  take  a  little  wine  or  brandy.  A  smelling- 
bottle  may  be  hekl  near,  not  to,  the  nose.  '  Reaction  is  not 
promoted  too  rapidly,  for  fear  of  secondary  consequonops. 


Militavii  Surgerif.  45 

The  period  of  daugcj-  from  collapse  being  over,  the 
patient  is  sedulously  watched,  that  overactiou  may  not  oi> 
eur,  the  risk  now  being  from  inHammation  ;  or,  the  stage  of 
excitement  being  happily  passed,  from  the  remote  effects  of 
the  injury,  If  the  concussion  Avas  at  all  severe,  all  bodily 
and  mental  excitement  must  be  for  a  long  time  avoided. 

Compression  of  the  brain  arises,  surgically  speaking,  from 
two  causes  only  :  effusion  of  blood  and  depressed  bone.  In 
the  former  case,  the  characteristic  symptoms — insensibility 
and  coma,  dilated  and  fixed  pupil,  stertorous  breathing,  and 
paralysis — frequently  do  not  come  until  some  thne  after  the 
receipt  of  the  injury.  The  first  symptoms  will  probably  be 
those  of  concussion,  or  exhaustion.  By-and-by  the  patient 
regains  his  strength,  gets  up,  talks,  or  walks,  and  then  sud- 
denly drops  down,  as  if  he  had  been  shot,  in  a  state  of  ut- 
ter unconsciousness.  The  effusion  of  l)lood,  kept  in  abey- 
ance during  the  collapse,  has  had  full  play,  tilling  empty 
places,  and  causing  unmistakable  effects.  8ucli  an  occur- 
rence will  bo  most  apt  to  happen  when  there  has  been  ex- 
tensive separation  of  the  dura  mater,  or  rupture  of  the 
middle  meningeal  artery.  If,  on  the  other  hand,  the  com- 
pression is  due  to  depression  of  the  skull,  the  symptoms  are 
nearly  always  immediate. 

"When  the  case  is  one  of  sanguineous  compression,  it  must 
1)0  treated  very  much  as  one  of  ordinary  apoplexy ;  at  first, 
by  efforts  at  gradual  reaction,  and  afterward  by  purgatives, 
bleeding,  and  means  to  favor  cerebral  accommodation  and 
prevent  inflammation.  The  trephine  is  not  thought  of 
unless  the  unconsciousness  obstinately  persists,  and  there  is 
reason  to  believe,  from  the  nature  of  the  phenomena, 
especially  the  existence  of  a  y^ound  or  contusion  on  the 
head,  that  the  blood  may  be  reached  by  the  instrument. 

Ginisltot  injuries  of  the  skull,  with  or  without  lodgment 
of  the  ball,  may  be  productive  merely  of  concussion  of  the 
brain,  or  of  concussion  and  compression.  AVhentlie  missile 
penetrates  the  bone,  and  tears  up  the  cerebral  tissues  and 
membranes,  death  usually  occurs  instantly,  or  within  a  short 
time  after  the  receipt  of  the  accident,  without,  perhaps,  any 
attempt  at  reaction.  Nevertheless,  a  number  of  cases  of 
injury  of  this  nature,  in  which  the  patient  either  partiallj-  or 
completely  recovered,  have  been  recorded  by  military 
surgeons.  In  some  instances  the  ball  merely  penetrates  the 
skull,  with  no  apparent  depression,  and  in  this  event  the 
treatment  should  evidently  be  very   simple,  being  limited. 


46  MiUtartf  Htmjcr;}. 


m  great  degree,  after  tlic  occurrence  of  reaction,  to  tlie  pre- 
vention of  inflammation  of  the  brain.  A  similar  courf^e 
shoiikl  be  adopted  when  tlie  bono  is  broken  and  only  slightly 
deproi^scd,  especially  if  there  l)e  no  urgent  or  obstinate 
symptoms  of  compression.  AVhcji,  on  the  contrary,  the 
bone  is  badly  fractm*ed,  comminuted,  or  forced  greatly 
beyond  the  natural  level,  the  proper  plan  is  to  tre]diine 
wliether  there  be  any  external  wound  or  evidences  of  com- 
]iression  or  not.  If  the  operation  be  neglected,  loss  of  life 
from  inflammation  will  be  sure  to  arise  within  the  flrst  six 
or  ten  day?;  after  the  receipt  of  the  injury.  In  the  i>unctar- 
cd  fracture,  as  it  is  named,  the  trephine  is  invariably  em- 
ployed at  the  earliest  moment,  however  flattering,  appar- 
ently, the  head  symptoms  may  be.  If  the  instrument  be 
withheld,  fatal  cerebritis  or  arachinitis  will  be  no  less  cer- 
tain than  when  the  bone  is  shattered  and  driven  down  upon 
the  brain. 

Fracture  of  the  skull  by  rc</<^/-cM'o«/;,  so  common  in  civil 
]tractice,  is  seldom  met  with  on  the  field  of  battle:  doubt- 
less for  the  reason  that  the  injury  is  hardly  ever  inflicted 
upon  the  to])  or  the  base  of  the  cranium,  as  it  is  when  a  ]ier- 
son  is  struck  upon  the  vortex  or  liills  upon  his  nates.  Tlu' 
most  frcf[uent  fracture  among  soldiers  is  the  punctured.  -\ 
ball  has  l)een  known  to  break  the  internal  tnhle  of  the 
skull  without  the  external. 

The  skull  is  sometimes  Irightfnlly  injured  without  any 
strious  lesion  of  the  scalp.  Nlaeleod  refers  to  a  case,  whicli 
occurred  at  the  Alma,  where  it  was  completely  destroyed 
by  a  glancing  shot,  without  any  material  implication  of  the 
soft  parts.  A  round  shot  ("en  "ricochet")  struck  the  scale 
from  an  ofliccr's  shoulder,  and  merely  grazed  his  head  as 
it  ascended.  The  result  was  instant  death.  The  skull  was 
so  completely  mashed  that  its  fragments  i-attlcd  under  its 
scalp  as  if  loose  in  a  l)ag.  Tlie  condition  of  the  brain  was, 
unfortunately,  not  ascertained. 

In  the  more  simple  Ibrms  of  iracturcs  of  the  skull,  how- 
ever induced,  the  practice  of  trephining  is  now  much  less 
common  than  formerly,  and  there  is  no  doubt  that  the 
patient  often  inakes  a  good  recovery,  though  it  is  by  no 
means  certain  that  sucli  a  i^erson  may  not  suiter  seriously, 
at  a  more  or  les-i  remote  period  from  epileptic  and  other  af- 
fections. 1  am  convinced  from  my  own  observation  that 
this  happens  not  unfrequcutly.  Dr.  Stromeyer,  surgeon-in- 
chief  in  thc^cbloswig-JTolstein  campaign  in  1840,  expresses 


MUitari/  iSaygery.  47 

Blroiii":  opposition  to  the  use  of  the  trephine  in  gunsliot  and 
other  Ihicturcs  of  the  skull,  even  with  depression,  on  the 
i;;round  that,  independently  of  the  mischief  intiicted  in  the 
oj)cration  upon  tlie  tissues,  admission  of  air  to  the  contused 
portion  of  the  brain  greatly  augments  the  danger  of  inliam- 
mation.  Of  41  cases  of  gunshot  fractures  of  the  skull  with 
depression,  reported  by  him,  o4  were  cured,  and  of  these  1 
oidy  had  been  trephined. 

"When  operative  interference  is  deemed  improper,  the 
most  simjile  treatment  should  be  enforced.  Any  probing 
that  may  be  necessary  should,  if  practicable,  be  performed 
with  the  finger,  and  the  wound  should  not  be  enlarged,  ex- 
cept when  we  are  compelled  to  elevate  depressed  or  remove 
loose  bone. 

When  trephining  is  recpiired,  it  should  be  done  as  early  as 
j>ossiblc,  and  without  chloroform  or  ether,  mdess  the  patient 
is  very  unruly,  as  the  auiesthetic  might  tend  to  provoke  iu- 
llaniniation  of  the  brain.     Every  particle  of  depressed  bone 
should  be  elevated,  and  such  portions  as  are  loose,  detached, 
or  driven  into   the  brain,  and   easily  accessible,   removed. 
All  bleeding  vessels  are   tied,  the  edges  of  the  wound   are 
f/cidb/  approximated  with  silver  sutures,  and  the   head,  well 
sliaved  and  raised,  "wrapped  in  warm  or  cold  water-dressing, 
as  may  be  most  grateful  to   ]iart   and  s^-stem.     The    great 
danger  after  all  severe   injuries   and  operations   upon   the 
skull  is  inHammtion  of  the  brain  and  of  its  membranes,  and 
to  the  prevention  of  this,  therefore,  the  surgeon  should  di- 
rect his  most  zealous  efiorts.     Tlic  patient  must  be  frequent- 
ly visited,  and  every   untoward  symptom  promptly  met  by 
appropriate  measures,  of  which   active  pm'gation,   loss  ol" 
blood  1)}'  venesection,  leeching  or  cupping,  a  restricted  diet, 
and'exclusion  of  light  and  noise  from  the  apartment,  with 
perfect  rest,  are  the  most  reliable. 

Wounds  of  the  brain  must  be  managed  upon  general 
principles;  all  foreign  matter  is  at  once  removed,  and  the 
parts  being  restored  as  nearly  as  may  be  to  their  normal 
]-elations,  the  surgeon  endeavors  to  keep  the  resulting  in- 
flammation within  proper  limits.  Most  of  such  lesions 
prove  fatal  Avithin  the  first  week  from  their  receipt.  If  the 
])atient  survive  for  any  length  of  time,  death  will  generally 
come  at  last  from  exhaustion,  cercbritis,  or  fungus. 

Tortious  cf  the  5/t«?^,  sliced  off  by  the  sabre  or  sword, 
should  be  replaced  and  secured  by  wire  sutures,  even  if 
they  are  aftachod  merely  by  small  shreds  of  the  scalp. 


48  Mditanj  »Sur(/crj. 


Scalp  woimds  of  every  description,  but  in  particular  the 
contused,  lacerated,  punctured,  and  iu:unsliot,  are  extremely 
jirone  to  be  followed  by  erysipelas  ;  death  may  also  occur 
from  ccrebritis,  arachnitis,  and  pyemia.  The  slii^htcst 
lesion,  then,  of  this  rocrion  of  the  body  should  be  zealously 
watched. 

Wounds  of  the  face  must  be  treatetl  witli  an  eye  to  the 
.'tvoidance  of  disfi<i:;urino;  scars,  by  wire  sutures  and  cold 
watcr-dressinii;.  When  a  large  portion  of  the  lower  jaw  is 
shot  away,  the  tonpiue  will  be  apt  to  fall  back  upon  the 
i^lottis,  causing  suftbcation.  The  organ  should  be  drawn 
t'orward  with  the  iinger  or  tenaculum,  and  the  patient  ob- 
serve the  prone  position  until  the  tendency  is  lost. 

One  of  the  great  sources  of  annoyance  and  danger,  in 
gunshot  wounds  of  the  face,  is  secondary  hemorrhage.  It 
h-equently  appears  soon  after  the  accident,  and,  although  it 
often  ceases  spontaneously,  it  is  sometimes  controlled  with 
much  difiiculty.  Tarah^sis,  partial  oi*  complete,  is  not  un- 
common, owing  to  injury  of  the  branches  of  the  facial 
nerve. 

In  the  management  oi  wounds  about  the  mouth, 
throat,  and  face,  great  care  must  be  taken  not  to  allow  the 
offensive  mucous  and  salivary  secretions  to  pass  into  the 
stomach.  The  neglect  of  this  precaution  is  apt  to  be  follow- 
ed by  a.  low  typhoid  state  of  the  system,  very  similar  to 
what  occurs  in  pyemia,  or  blood  poisoning.  I  have  repeat- 
edly witnessed  these  effects  after  operations  upon  the  jaws. 
mouth,  and  oven  the  nose. 

In  fractures  of  tlie  1)oncs  of  the  face  from  gunshot  an  ex- 
ception should  be  made  to  the  general  rule  of  removing 
fragments  which  are  nearly  detached,  observation  having 
shown,  says  Mr.  Macleod,  that  the  large  supply  of  blood  in 
this  region  will  enable  themto  resume  their  connection  with 
the  other  tissues,  in  a  Avay  that  would  l)e  fatal  to  similarly 
placed  portions  in  other  situations, 

(lunshot  and  other  wounds  of  the  rAto/!  are,  as  stated  clsf- 
Vv'here,  extremely  fatal ;  death,  if  the  lesion  be  at  all  severe, 
l)cing  usually  speedily  caused  by  shock,  hemorrhage,  or 
asphyxia  ;  or,  at  a  more  or  less  remote  period,  by  inllam- 
mation  and  eifusion.  "Wlien  the  lungs  are  wounded,  the 
characteristic  symptoms  will  be  hemopt3'sis,  with  sultbcative 
cough,  great  prostration,  and  excessive  alarm.  A  copious 
How  of  blood  may  take  place  in  the  thoracic  cavity  from  a 
Avound  of  one  of  the  intereoRtal  arteries. 


Militarii  Sargcrij.  41' 

Any  foreign  matter  that  is  easily  accessible  is  at  once 
removed,  but  ofticions  probing  is  out  of  the  question.  The 
wound,  if  small  and  unaccompanied  by  serious  hemorrhage, 
is  closed  in  the  usual  manner,  the  chest  being  firmly  en- 
circled by  a  broad  bandage,  to  compel  diaphragmatic  res- 
piration. Under  opposite  circumstances,  it  is  kept  open,  the 
patient  lying  upon  the  atibctcd  side  to  favor  the  escape  of  blood 
with  as  much  elevation  of  the  head  as  the  case  may  admit  of 
The  main  reliance  for  arresting  pulmonary  bleeding  is  upon 
venesection,  copious,  and  frequently  repeated,  unless  the  ex- 
haustion amounts  to  absolute  collapse.  Sugarof  lead,  opium, 
and  veratrum  viride  arc  frequently  exhibited,  sinapisms  arc 
applied  to  the  extremities,  and,  in  short,  everything  is  done 
to  control  cardiac  action.  Intiammatory  symptoms  arc 
counteracted  in  the  usual  manner,  and  oflused  flnids,  caus- 
ing oppression,  and  resisting  ordinary  measures,  are,  un- 
hesitatingly, evacuated  by  puncture,  as  the  only  chance  of 
escape. 

-  Wounds  of  the  /trarf  and  (^or/^^,  of  whatever  nature,  are 
usually  fatal ;  now  and  then,  however,  an  astonishing  ex- 
ception occurs. 

Wounds  oiih(^ abdomen^  merely  penetrating  its  walls,  but 
not  its  contents,  are  brought  together  by  sutures,  extending 
down  nearly  to  the  peritoneum,  otherwise  they  will  be  fol- 
lowed by  hernia.  When  they  involve  the  intestine,  and  are 
incised,  they  are  sewed  up  with  a  iiuc  needle  and  silk 
thread,  either  interruptedl}''  or  continuously,  the  ends  of  the 
ligature  being  cut  off  close. 

Contusions  of  the  walls  of  the  abdomen  by  round  shot 
are  among  the  most  dangerous  injuries  to  which  the  body 
is  exposed,  often  rupturing  both  the  hollow  and  solid 
viscera,  and  rapidly  causing  death,  without  much  apparent 
sign  of  so  severe  an  accident.  The  most  important  symp- 
toms of  these  contusions  arc  vomiting,  and  pain  in  the 
abdomen;  and  the  great  object  of  the  treatment,  in  the 
event  the  patient  survives  their  immediate  eficcts,  is  the 
]n'evention  of  peritonitis,  which  often  comes  on  in  the  most 
stealthy  manner.  Laceration  of  an  internal  organ  is  near- 
ly always  promptly  fatal.  Shell  wounds  of  the  walls  of 
the  abdomen  arc  generally  followed  by  extensive  sloughing. 
Abscesses  among  the  muscles  of  the  abdomen  are  not  un- 
common after  gunshot  injuries. 

Balls  often  traverse  the  walls  of  the  abdomen  for  a  con- 
siderable distance  without  entering  its  cavity,  or  they  pass 
In  witliout  injuring  any  of  tlie  contained  viscera. 


,■)(»  MiliUtri/  tSwgcnj. 

"The  fatality  of  penetrating  woiindf?  of  the  belly,"  ol)- 
.sei'vcs  Maclcod,  "will  depend  much  on  the  point  of  theii- 
intliction.  r>allr5  entering  the  liver,  kidneys,  or  spleen  arc 
well  known  to  ho  usually  mortal,  although  exceptional  cases 
are  not  rare.  Wounds  of  the  great  gut  are  also  always 
recognized  as  much  less  lormidahlc  than  those  Avhich  im- 
plicate the  small.  Thomson  saw  only  two  cases  of  wounds 
of  the  small  gut,  after  AVaterloo,  in  the  way  of  recovery: 
hut  Larrey  reports  several.  (lunshot  wounds  of  the  stomach 
are  also  exceedingly  fatal.  J^audens  records  a  i-enuirkahlo 
case  of  recovery,  although  complicated  with  severe  head 
injuries.  The  syncope  which  followed  the  severe  hemorr- 
hage in  this  ease  lasted  for  ten  hours,  and  douhtles.s  assisted 
along  with  the  empty  state  of  the  stomach  at  the  moment 
of  injury,  in  preventing  a  fatal  issue." 

(Tunshot  wounds  of  the  bladder  occasionally  occur  ;  the 
ball  may  penetrate  the  organ  in  any  direction,  and  at  the 
same  time  commit  extensive  havoc  in  the  neighboring 
l)arts,  both  soft  and  osseous.  tSuch  lesions  arc  generally 
fatal.  Simple  gunshot  wounds,  on  the  contrary,  are  some- 
times recovered  from,  especially  when  tlicy  are  treated  by 
the  retention  of  the  catheter,  thus  allowing  the  urine  to  How 
oil  as  last  as  it  descends  from  the  kidneys.  The  operation  of 
laying  open  the  wounded  viseus  through  the  perineum,  as 
originally  proposed  by  Dr.  "Walker,  of  Massachusetts,  might 
be  performed  in  such  a  contingency.  Such  a  procedure 
would  be  much  more  likely  to  prevent  urinary  iniiltration 
than  the  catheter,  however  carefully  retained,  during  the 
detachment  of  the  sloughs,  as  well  as  before  the  contiguous 
structures  have  been  glazed  with  lymph. 

Balls,  pieces  of  cloth,  fragments  of  bone,  and  other  foreign 
bodies,  if  retained  in  the  bladder,  gejierally  serve  as  nuclei 
calculi,  and  sliouhl,  therefore,  ])c  as  speedily  extracted  as 
possible,  either  through  the  perineum,  or  by  means  of  thf 
ibreeps  or  lithotriptoi-.  C^uite  a  number  of  cases,  in  which 
the  operation  of  lithotomy  was  successfully  performed  for 
the  purpose  of  effecting  the  riddance  of  balls  and  other  ex- 
traneous substances,  have  been  reported  by  different  writers, 
as  Morand.  Larrey,  J'audens,  Langenbeck,  Guthrie,  and 
ITutin. 


ClIAPTEKLX. 

DISEASES   INCIDENT   TO  TROOl'S. 

The  diseases  which  attend  armies,  or  molest  soldiers  hi 
camps,  garrisons,  and  hospitals,  and  which   so   often   dooi- 


MllUarii  Surtjery.  51 

mate  their  ranks,  and  even,  at  times,  almost  annihilate 
whole  regiments,  are  the  ditierent  kinds  of  fevers,  especial- 
ly typhus  and  typhoid,  dysentery,  diarrha^a,  and  scurvy. 
These  are,  emphaticalh',  the  enemies  of  military  life,  doing- 
infinitely  more  execution  than  all  the  weapons  of  war,  Jiow- 
ever  adroitly  or  efficiently  wieklcd,  put  together.  Pneu- 
monia, pleurisy,and  liepatitis,  of  course,  slay  their  thousands, 
and  various  epidemics,  especially  cholera,  not  unfrequently 
commit  the  most  frightful  ravages.  "War,"'  says  Johnson, 
"has  means  of  destruction  more  formidahle  than  the  cannon 
and  the  sword.  Of  tlie  thousands  and  tens  of  tliousands 
that  have  perished,  how  small  a  proportion  ever  felt  the 
stroke  of  an  enem}- 1"'  Frederick  the  Great  used  to  say  that 
fever  cost  him  more  men  than  seven  pitched  battles,  and  it 
has  long  l>ecn  a  matter  of  history  that  nuorc  campaigns  arc 
decided  by  sickness  than  by  the  sword.  The  great  mortal- 
ity which  attended  our  armies  in  Mexico  Avas  occasioned, 
not  by  wounds  received  in  battle,  but  l)y  tlic  diseases  inci- 
dent to  men  carrying  on  their  military  operations  in  an  in- 
hospitable climate,  badly  fed,  subjected  to  fatiguing  marches, 
and  obliged  to  use  unwholesome  Avatcr.  Tliousands  perish- 
ed, during  their  absence,  from  fever,  dysentery,  and 
diarrhoea,  and  a  still  greater  number  from  the  effects  oi' 
these  diseases,  after  the  return  of  the  troops  to  then-  native 
soil.  The  latter  affection,  in  particular,  pursued  many,  like 
a  relentless  foe,  to  their  graves  long  after  they  had  been 
cheered  by  the  sight  of  their  homes  and  friends. 

In  the  war  in  the  Crimea  disease  destroyed  incomparably 
more  soldiers  than  the  sword,  the  musket,  and  the  cannon. 
Typhus  and  typhoid  fever,  dysentery,  diarrha'a,  scurvy,  and, 
lastly,  malignant  cholera,  annihilated  vast  numbers,  both  in 
the  British,  French,  and  Russian  ranks.  According  to  \)y. 
Macleod,  whose  "Xotes  on  the  Surgery  of  the  '^V\ar  in  the 
Crimea,"  are  so  well  known  to  the  profession,  the  propor- 
tion of  those  lost  among  the  13ritish  b^^  sickness  to  those 
Jost  by  gunshot  and  other  injuries,  was,  during  the  entire 
campaign,  as  16,211  to  1761,  exclusive  of  those  killed  in 
action.  The  difference  he  supposed  to  have  been  still 
greater  among  the  French  and  Russian  forces.  h\  Decem- 
ber, 18.">4,  and  in  January,  1855,  not  less  than  14,000  French 
soldiers  were  admitted  into  the  Crimeaii  ambulances  on 
account  of  disease,  Avhereas,  during  the  same  period,  only 
1500  were  admitted  on  account  of  wounds.  Of  the  whole 
nnndicr  nearlv  2000  died.     During  the  Inst   six  months  of 


o2  Jlilifari/  Siirgei'ii. 

the  campaign,  in  wliich  the  city  was  Btormed  and  taicen,  the 
French  liad  21,9.i7  wounded  as  an  ottset  against  101,128 
(•ascs  of  Disease."-^  At  AValchcrcn,  in  1800,  the  i^ritishlost 
oue-tliird  of  their  troops  by  disease,  and  only  16  per  cent, 
by  wounds.  In  the  Peninsular  war,  from  January,  1811. 
to  May,  1814,  out  of  an  cfiectivc  force  of  01,500  men  only 
42-4  per  1000,  says  Macleod,  Avcro  lost  by  Avounds,  while 
118-0  were  lost  by  disease. 

The  number  of  sick  that  may  be  cx}»ected  to  bo  constant- 
ly on  hand  during  any  given  campaign  is  estimated,  on  an 
average,  at  10  per  cent.;  but  tliis  proportion  must  necessar- 
ily be  exceeded,  especially  in  an  invading  army,  Avith  raw. 
midisciplincd,  and  unacclimated  troops.  This  was  eminent- 
ly true  even  in  the    Crimea,    in  a  climate   comparatively 
licalthy,  within  a  few  miles  of  the  sen.     AVc  may  well   im- 
agine what  wouhl  be  the  effects  of  the  climate  of  the  South 
upon  the  Xorthern  troops,  if  tJiey  were  to  pass  far,  during 
the  hot  season,  beyond  Alason  and   Dixon's   line.     .Disease 
in  its  worst  form,  would  be  sure  to  invade  and   thin  their 
i-anks  at  every  step.     Fever — typhoid,  typhous,  remittent, 
intermittent,  and  yellow — dysentery,  diarrhcea,  scurvy,  pneu- 
monia, and  inflammation   of  the   liver   would    accomplish 
more,  infinitely  more,  for  the  Southern  cause  than  all  the 
weapons  of  war  that  could  be  placed  in  the  hands  of  the 
Southern  people.     Typhoid,  typhus,  and  yellow  fever,  dys- 
cnterj',  diarrha^a,  and  scurvy  would,  in  all   human   proba- 
])ility,  soon  become  epidemic,  and  occasion  a  mortality  truly 
appalling.     The  Southern  soldier,  on   the  contrary,   thor- 
oughly acclimated  as  he  is,  would  suffer  comparatively  little. 
The  British  in  the  C'rimcan  war  lost  r),l>10  men  from  diar- 
rhoea and  dysentery,    the   whole  number   of  cases   having 
been  52,442,  affording  thus  a  mortality  of  11-20  per  cent. 
Cholera,  of  which  there  were   7,575   cases  altogether,   de- 
stroyed 4,518  or  in  the  ratio  of  59-57  per  cent.  Typhus  fever 
killed  285  out  of  828  cases ;  fever  not  typhus,  3,161,  out  ol 
o0,o70.     The  French  and  Jlussian   troops  suffered  in  still 
larger  numbers  from  these  diseases.     Macleod  asserts  that 
the  former  lost  their  men  by  typhus   fever  by  thousands, 
and  the  latter  by  tens  of  thousands.     The  British  suffered 
but  little  from  intermittent  fever,  whereas  this  disease   did 


■'Macleoil.  op.  clt,,  p.  01 


Military  Surgery.  53 

great  mischief  among  the  French,  causing  serious  mortali- 
ty, either  directly  or  indirectly,  besides  disqualifying  large 
numbers  for  service. 

Scurvy  was  another  dreadful  enemy  which  the  British 
and  French  troops  were  compelled  to  encounter  in  the 
Crimea.  It  prevailed  more  or  less  extensively  for  a  long 
time  and  served  to  impart  its  livery  to  the  other  diseases  of 
the  soldiery,  masking  their  character,  and  remarkably  aug- 
menting their  virulency. 

Considering,  then,  the  frequency  of  the  occurrence  o± 
these  diseases,  and  their  excessive  fatality,  it  behooves  the 
military  surgeon  to  use  every  means  in  his  power  to  guard, 
in  the  tirst  place,  against  their  outbreak,  by  the  employ- 
ment of  proper  hygienic  or  sanitary  measures,  and  in  the 
next,  to  treat  them  with  all  possible  diligence  and  judg- 
ment when  their  development  is  unavoidable.  It  is,  of 
course,  impossible,  in  a  work  of  this  description,  to  enter 
into  any  details  upon  the  subject;  but  there  are  several 
points  which  cannot,  I  conceive,  be  too  forcibly  impressed 
upon  the  mind  of  the  military  practitioner.  I  refer  to  the 
great,  the  paramount  importance  of — 1st,  proper  isolation 
of  the  sick,  or,  what  is  tlie  same  thing,  the  importance  of 
not  crowding  them  together;  2d  1 3',  free  ventilation;  3dly, 
bodily  cleanliness ;  4tlily,  little  medicine  ;  5thly,  a  good 
supply  of  fresh  vegetables  and  fruits,  especially  oranges 
and  lemons ;  6thly,  careful  and  tender  nursing. 

Painful  experience  has  shown  in  all  parts  of  the  world, 
that  the  crowding  together  of  the  sick  and  wounded  is  one 
of  the  worst  calamities  that  can  befall  them.  For  want  of 
this  precaution,  diseases,  otherwise  easih-  manageable,  often 
assume  an  epidemic  character,  or,  in  the  absence  of  this 
character,  often  bafHe  the  best  directed  efforts  for  their  re- 
lief. AVhen  the  wounded  are  crowded  together  they  fre- 
quently become  the  victims  of  erysipelas,  hospital  gan- 
grene, pyemia,  and  phlebitis ;  occurrences  which,  under 
better  regulations,  might  in  many  cases  be  entirely  pre- 
vented. 

Of  the  propriety  of  constant  and  thorough  ventilniion,  it 
is  unnecessary  to  speak.  If  pure  air  is  so  essential  in 
health,  it  is  easy  enough  to  see  how  important  it  must  be  in 
sickness. 

CleanUness  of  body  should  be  regarded  as  a  religious 
duty ;  it  may  be  effected  with  the  sponge  and  tepid,  cool  or 
cold  water,  according  to  the  exigencies  of  the  case,  and  can- 

4 


64  31iLUcci^y  tSurgery. 

not  be  performed  too  frequently  or  too  tlioroiiglil y,  care 
being,  of  course,  taken  not  to  worry  or  fatigue  the  ]»atient. 
In  some  instances  the  water  may  Ije  medicated  with  com- 
mon salt,  i)otassa,  vinegar,  or  Labarraque's  solution.  Noth- 
ing is  generally  more  grateful  to  the  sulierer,  in  the  difter- 
ent  kinds  ot  fevers,  than  frequent  sponging  of  the  surface 
wirh  cool  or  tepid  water. 

Tlie  use  of  heroic  medicines,  or  ot  any  medicines  in  large 
do^es,  in  these  diseasee,  and  also  incases  of  severe  wounds, 
cannot  be  too  severely  reprobated.  More  men,  there  is 
reason  to  believe,  have  been  killed  in  this  manner  in  the 
armies  and  navies  of  the  world  than  by  the  sword  and  the 
cannon.  Let  medicines,  tlien,  be  administered  sparingly. 
Let  the  secretions  be  well  seen  to;  but  purge  little,  and  use 
depressants  with  all  possible  Aveariness.  Give  iced  water 
but  not  too  freely,  and  lumps  of  ice  when  there  is  much 
thirst  with  gastric  irritability  and  excessive  restlessness. 
Mild  diaphoretics  and  anodynes,  will,  as  a geneiid  rule,  be 
liighly  etticacious,  but  the  latter  should  be  exhdjited  with 
great  caution  when  there  is  ccrubral  oppression.  Lemon- 
juice  and  potassa  are  indispensable  in  scurvy,  or  where 
there  is  a  marked  tendency  to  scorbutic  disease.  Quinine 
is  one  of  the  greatremcdics  in  most,  if  not  in  all,  of  these 
diseases,  especially  when,  as  is  so  often  the  case,  they  are 
associated  with  a  malarious  origin.  The  good  average 
dose  is  from  two  to  Hve  grains,  repeated  from  three  to  five 
times  in  the  twenty-four  hours.  AV'hen  marked  debility 
prevails,  the  best  stinmlants  arc  brandy,  in  the  form  of 
milk-punch  or  toddy,    and  Madeira,  Port,  or  Sherry  wine. 

Immense  suiiering  and  loss  of  life  are  often  occasioned 
for  the  want  of  fresh  vegetables  and  fruits  in  military  oper- 
ations, as  well  as  in  the  garrison  and  the  hospital.  A  daily 
supply  of  these  articles  "should,  therefore,  be  provided  at 
almost  any  hazard  and  expense.  In  all  low  states  of  the 
system,  however  induced,  the  strength  can  never  be  rapid- 
ly brought  up  without  a  diet  \N'iiich  partakes  more  or  less 
of  this  character. 

There  is  a  form  of  <f)jscnleri/,  very  common  in  India. 
wbicJi  is  exceedingly  apt,  when  large  masses  of  troops  arc 
habitually  congregated  together,  to  assume  an  epidemic 
character  ;  and  it  is  for  this  reason  that  it  has  often  been 
supposed  to  be  contagious.  For  such  an  opinion,  hewever, 
there  does  not  seem  to  bo  any  valid   reason.     Ballingall, 


Military  Surgery.  55 

wlio  witnessed  at  least  2000  cases  of  this  disease,  asserts 
that  he  never  once  met  with  a  circumstance  tending  to 
create  sucli  a  suspicion  ;  and  the  views  advanced  hy  tliis 
eminent  surgeon  are  those  now  pretty  generally,  if  not 
universally,  entertained  by  the  British  practitioners  ii,i 
India. 

"The  remote  causes  ot  dysentery  in  India  are  conceived 
to  be  heat,  particularly  when  combined  with  moisture  ;  the 
immediate  and  indiscriminate  use  of  fruits  ;  the  abuse  of 
spirituous  liquors,  and  exposure  to  currents  of  wind  and  to 
noxious  niglit-dews."  Troops  recently  arrived  from  Eu- 
rope arc  particularly  prone  to  the  disease. 

Tropical  dysentery  presents  itself  in  two  varieties  of 
form,  the  acute  and  the  chronic.  The  first,  which  is  an  ex- 
tremely fatal  disease,  is  seated  in  the  rectum  and  colon,  the 
latter  being  often  involved  through  nearlj'  its  entire  extent, 
and  it  frequently  commits  very  serious,  if  not  irreparable, 
mischief  in  these  structures  before  the  patient  and  the  at- 
tendant are  aware  of  its  true  cliaracter,  owing  to  the  ab- 
sence of  urgent  pain  and  pyrexia.  In  general  the  attack 
is  ushered  in  by  the  ordinary  symptoms  of  diarrhani,  such 
as  griping  pain  in  the  bowels  and  frequent  calls  to  stool 
with  excessive  straining,  the  evacuations  being,  at  first, 
thin  and  copious  but  without  fetor  and  but  little  streaked 
with  blood.  The  tongue  skin,  and  pulse  are  nearly,  per- 
haps entirely  normal.  Gradually  the  pain  becomes  more 
violent,  as  well  as  more  fixed,  and  is  felt  in  both  iliac  re- 
gions, or  even  along  the  whole  track  of  the  colon  ;  the  dis- 
charges consists  chiefly  of  blood  and  mucus,  or  of  a  fluid 
resembling  water  in  which  fresh  beef  has  been  macerated  ; 
the  tongue  is  covered  with  a  white  coat ;  the  skin  is  either 
hot  and  dry,  or  bathed  with  clammy  perspiration  ;  and  the 
straining  is  so  excesssve  as  to  occasion  prolapsus  of  the 
rectum.  The  pulse  is,  even  at  this  stage,  often  but  little 
aflected,  being  perhaps,  only  somewhat  increased  in  quick- 
ness. Sometimes,  however,  if  is  very  full,  bounding,  and 
vibrator}-,  without  much  velocity,  and  ^\hen  this  is  the  ease 
it  always,  according  to  Ballingall,  forebodes  evil.  Toward 
the  close  of  the  attack,  the  passages  are  frequently  invol- 
untary and  intolerably  fetid,  gangrenous  portions  of  the 
mucous  coat  of  the  bowel  are  sometimes  extruded,  and 
the  surface  of  the  body  emits  a  peculiar  cadaverous  smell. 
The  average  period  at  which  death  occurs  is  about  one 
week,  but  many  cases  linger  on  much  longer. 


Miliiarij  ISurgery. 

The  remedies  upon  whicli  the  ludia  practitioners  mainly 
rely  in  the  treatment  of  this  horrible  form  of  dysentery 
are  venesection,  mercury,  and  opium,  leeches,  purgatives, 
diaphoretics,  warm  bathinG:,  blisters,  and  cnemata,  beinsj 
employed  as  auxiliaries.  Venesection  is  always  practiced 
early,  and,  even  when  the  patient  is  not  very  robust,  bold- 
ly, it  being,  apparently,  regarded  as  the  sheet  anchor  of  the 
jjhysician's  hope.  Calomel  is  administered  in  doses  of 
from  ten  to  twenty  grains,  along  with  two  or  three  grains 
of  opium,  twice  or  thrice  in  the  twenty-four  hours  ;  and, 
while  profuse  salivation  is  discountenanced,  production  of 
slight  ptyalism  is  generally  aimed  at. 

Bach  treatment  as  this  seems  altogether  frightful  to  the 
modern  American  practitioner ;  it  strikes  him  as  unneces- 
sarily harsh,  and  as  well  calculated  to  augment  the  mortal- 
ity of  the  disease.  "We  might,  in  this  country,  perhaps 
bleed,  and  that  pretty  freely,  at  the  very  commencement  of 
an  attack  of  dysentery;  at  all  events,  leech  very  co[)iously, 
but  we  would  certainly  draw  blood  sparingly  if  the  attack 
had  already  made  serious  constitutional  inroads,  or  if  it  was 
of  an  epidemic  character,  and,  as  to  giving  mercury  with  a 
view  to  ptyalism,  however  slight,  few  men  would,  I  presume, 
be  so  fool-hardy.  The  India  practitioners  do  not,  it  ap- 
pears, employ  quinine  in  the  treatment  of  this  form  of  dys- 
entery ;  a  remedy  so  extremely  needful  in  many  cases  of 
this  disease  as  it  prevails  in  this  country,  especially  in  our 
Southern  latitudes,  where  it  is  not  unfrequently  of  a  malar- 
ious origin. 

The  chronic  form  of  India  dyscnter}-,  termed  hepatic  flux, 
more  frequently  attacks  persons  who  have  been  for  some 
time  inured  to  the  climate  of  that  country,  and  is  always 
associated  with  biliary  derangement.  ''This  flux,  like  the 
other,  often  assumes  at  its  commencement  the  appearance 
of  a  common  diarrhoea,  and  becomes  afterward  character- 
ized by  frequent  and  severe  flts  of  griping,  resembling  colic 
pains,  particulary  urgent  about  the  umbilical  region.  Each 
attack  of  griping  is  generally  succeeded  by  a  call  to  stool, 
and  the  evacuations  are  always  unnatural  in  color  and  con- 
sistence, free  from  any  admixture  of  blood,  but  generally 
of  a  yeasty  or  frothy  appearance,  and  accompanied  with 
large  discharges  of  flatus  ;  while  in  passing  they  arejttend- 
ed  with  a  sense  of  scalding  about  the  anus.  The  Pftient, 
after  each  evacuation,  icels  considerably  relieved,  and  hopes 
to  enjoy   an  interval    of  ease,  but  the  recurrence   of  the 


Military  Sunjery.  57 

fyripiug,  accompanied  with  a  sensation  of  air  passing  tlirpu";!! 
the  bowels,  and  succeeded  again  by  a  call  to  stool,  give  him 
little  respite.  From  the  commencement  of  the  attack,  the 
patient  complains  of  nausea,  want  of  relish  for  his  food, 
and  preternatural  thirbt,  attended  often  with  a  disagreeable 
taste  in  the  mouth.  The  tongue  is  furred  or  loaded,  ^nd 
not  unfrequently  covered  with  a  yellow  bilious  coat.  The 
pulse  is  quickened  and  the  skin  parched.* 

Cholera  morbus rawi^t,  necessarily,  in  this  country,  especially 
in  our  Southern  latitudes,  and  during  the  hot  summer 
months,  be  a  more  or  less  frequent  attendant  upon  camp 
life,  although  much  may  be  done,  by  a  proper  observance  of 
hygienic  laws,  to  prevent  it.  When  the  dis(3ase  breaks  out 
it  cannot  l)c  arrested  too  speedily.  The  most  appropriate 
remedies,  particularly  in  its  earlier  stages,  are  perfect  quie- 
tude, abstinence  from  drink,  sinapisms  to  the  epigastrium, 
and  an  efficient  dose  of  morphia  and  camphor,  or  even  mor- 
phia alone.  If  torpor  of  the  liver  exists,  blue  mass  or  a 
few  grains  of  calomel  may  be  advantageously  combined 
with  the  anodyne.  The  swallowing  of  small  lumps  of  ice 
will  greatly  assist  in  allaying  the  gastric  irritability.  A 
mustard  and  salt  emetic  will  be  indicated  if  the  stomach  is 
loaded  withingcsta.  The  bowels  are  quieted  with  an  ano- 
dyne enema  ;  and  to  relievo  thirst,  and  reduce  heat  of  skin, 
the  surface  is  frequently  sponged  with  cool  or  tepid  water. 
A  combination  of  carbonate  of  potossa  and  acetated  tinc- 
ture of  opium,  with  fresh  lemon-juice,  in  peppermint  or 
camphor  water,  will  often  act  like  a  charm  in  relieving  the 
gastric  and  intestinal  irritability,  the  cramps,  and  other  dis- 
tressing symptoms. 

The  exposure  of  the  soldier,  both  in  the  tent  and  on  the 
field,  renders  him  extremely  prone  to  rheumatism.,  frequent- 
ly attended  with  high  inflammatory  excitement  and  severe 
pain.  Such  an  attack  is  often  effectually  put  to  flight  if,  at 
its  inception,  it  be  treated  with  a  large  anodyne  and  diapho- 
retic mixture,  as  fifteen  grains  of  Dover's  powder,  a  third 
to  half  a  grain  of  sulphate  of  morphi  with  a  fourth  of  a 
grain  of  tartar  emetic,  or,  what  is  perhaps  still  better,  a 
drachm  of  the  wine  of  colchicum  in  union  with  a  full  dose 
of  mcwthia  or  black  drop.  When  the  disease  has  already 
made  wme  progress,  an  active  purgative  should  precede  the 
exhibition  of  these  medicines, 

♦BallingalFs  Military  Surgery,  p.  511,  ISM. 


58  Militz^ry  Surgery. 

Spre  throat,  tonsilitis,  and  catarrlial  aftections,  or,  what 
in  common  language  are  called  colds,  are  very  common 
among  soldiers,  especiall}'^  the  raw  troops  just  mustered  into 
service,  ill  clothed,  inexperienced,  and  unaccustomed  to 
camj)  life.  The  moment  such  disease  sets  in,  no  matter 
ho^i'  light  it  may  be,  the  person  should  be  compelled  to  re 
port  himself  at  the  surgeon's  quarters,  iu  oi'der  that  he  may 
receive  the  necessary  attention  and  advice.  Generally  an 
attack  of  this  kind  will  promptly  yield  to  a  trifling  pre- 
scription, as  a  little  hot  drink,  a  mild  aperient,  or,  better 
still,  a  quarter  of  a  grain  of  morphia,  a  grain  of  opium,  or 
a  large  dose  of  Dover's  powder. 

In  ail  army  not  under  strict  discipline,  or  where  proper 
care  is  not  observed  in  Q\\\\^\\ng,inania  a jpoiu  is  very  apt  to 
show  itself,  much  to  the  annoyance  of  the  nurses  and  the 
physicians.  It,  in  such  a  case,  the  patient  be  not  well  se- 
cured, he  ma}',  in  his  perverted  military  ardor,  do  serious 
mischief  to  himself  and  to  his  attendants.  A  moderately 
active  mercurial  purge  at  the  outset  of  the  disease  will  often 
go  far  in  quieting  the  system  and  in  abridging  the  attack. 
After  the  medicine  has  operated,  a  mild  opiate  and  seda- 
tive treatment  will  generally  be  the  most  soothing.  Al 
coliolic  stimulants  are,  in  general,  to  be  witheld. 

A^o.s7(///y/a  is  another  com[)laint  liable  to  assail  the  soldier, 
even  the  hardiest,  especially  if  he  is  a  person  of  strong  do- 
mestic attachments,  or  engaged  in  an  "altairc  du  coeur."  It 
is  more  apt  to  show  itself  in  soldiers  enlisting  for  the  for- 
eign service,  or  in  those  who  are  forcibly  expatriated,  and  is 
often  attended  with  great  suiiering,  terminating  in  con- 
firmed melancholy.  It  is  characterized  by  a  love  of  soli- 
tude, a  vacant,  stultified  expression  of  the  countenance,  a 
morose,  peevish  disposition,  absence  of  mind,  pallor  of  the 
cheeks,  and  progressive  emaciation.  Many  of  Bonaparte's 
troops,  during  the  campaign  in  Egypt,  sulfered  from  this 
complaint ;  some  in  a  very  distressing  degree.  In  this 
country,  nostalgia  will  not  be  likely  to  occur,  at  least  not  to 
any  extent,  as  our  people  are  essentially  of  a  roving  habit, 
and  of  an  eminently  social  disposition.  The  treatment  is 
rather  moral  than  medical ;  agreeable  amusements,  kind- 
ness, gentle  but  incessant  occupation,  and  the  proyso  of 
an  early  return  to  home  and  friends  constituting  t^  most 
important  means  of  relief. 

It  is  impossible,  even  under  the  most  rigid  discipline,  to 
prevent  gonorrhea  among  soldiers.     They  will  expose  them- 


31iliiari/  Himjeiij.  59 

selves,  in  spite  of  all  that  can  bo  done  to  prevent  it,  and 
tliej  often  pay  a  heavy  penalty  for  their  indulgence,  not 
only  from  the  suffering  entailed  by  the  primary  disease,  but 
its  different  complications,  especially  chordce,"  cystitis,  and 
orchitis.  The  symptoms  of  gonorrlioea  are  too  well  under- 
stood to  require  enumcratioirhcre.  The  treatment  should, 
from  the  start,  be  rigidly  antiphlogistic  ;  by  rest,  low  diet, 
active  purgation,  and  the  antimo'nial  and*^  saline  mixture, 
with  the  addition  of  a  small  (quantity  of  copaiba.  The 
penis  and  scrotum  are  well  supported^,  and  covered  with 
warm  water-dressing,  the  former  organ  being  bathed  in 
tepid  salt  water,  at  least  thrice  daily,  for  twenty  minutes  at 
a  time.  When  the  discharge  is  greatly  lessened,  but  not 
till  then,  recourse  is  had  toTinjections  of  lead,  sulphate  of 
zinc,  or  nitrate  of  silver,  at  first  very  nuld  and  gradually 
increased  in  strength,  repeated  every  six,  eight  or  twelve 
hours.  ^  The  treatment  is  continued,  'in  a  modified  form,  for 
about  five  days  after  all  tlie  specific  symptoms  have  van- 
ished. 

Ghordeciii  best  relieved  by  a  full  anodyne,  as  "half  a  grain 
of  morphia,  in  union  with  the  fourth  of  a  grain  of  fartar 
emetic,  given  toward  bedtime,  or  by  a  large'enema  of  lau- 
danum ;  with  warm  water-dressiugs'to  the  genitals. 

For  the  YcYiai  oi  ciislitis  the  most  appropriate  remedies 
are  anodyne  diaphoretics,  in  iho  form  of  Dover's  powder, 
or  a  solution  of  morphia  and  tartar  emetic,  aided  by  the 
free  use  of  bicarbonate  of  soda  and  moderate  quantities  of 
diluents. 

Orchitis  is  treated  by  suspension  of  the  aftected  organ, 
w-ithstrong  lead  and  anodyne  lotions,  and  the  judicious  ex- 
hibition of  antimou}',  in  union  with  morphia  or  black  drop. 
_  Chancres  must  be  thoroughly  cauterized  at  the  beginning, 
either  with  nitrate  of  silver,  nitric  acid,  or  acid  nitrate  of 
mercury ;  and  subsequently,  or  after  the  disease  has  made 
some  progress,  like  any  common  sore,  with  mild  measures ; 
mercury  being  studiously  withheld,  except  in  the  hard  form 
of  the  disease,  but  not  even  then  while  there  is  much  in- 
flammation or  inordinate  constitutional  excitement.  In  a 
word,-  all  hc'irsh  measures  must  be  avoided.  The  patient 
will^cnerally  do  a  thousand  times  better  without  thauAvith 
mei^ry.  The  greatest  possible  attention  must  be  paid  to 
cleanliness,  and  for  this  purpose  the-  parts  should  be  fre- 
quently bathed  in  tepid  salt  water,  aided  by  the  syrino-e  if 
there  Ije  a  tight  prepuce.     The  best  local  application  is  the 


60  3Iilitary  Surgery. 

warm  water-dressing,  covering  in  the  entire  genitals  ;  if 
much  swelling  and  ])ain  are  present,  it  m:.y  be  advanta- 
geously medit-ated  with  lead  and  opium.  As  the  iiitlam- 
niation  subsides,  the  sore  may  be  dressed  with  some  j^ently 
stimulating  lotion,  as  two  grains  of  tannin,  the  eighth  ot  a 
grain  ot  sulphate  of  copper,  and  half  a  drachm  of  laudanum 
to  the  ounce  of  water,  a  weak  mixture  of  sherry  and  water, 
or  a  solution  of  nitrate  of  silver,  zinc  or  iodide  of  iron.  If 
the  ulcer  is  disposed  to  spread,  or  presents  a  sloughy  or  un- 
healthy aspect,  it  will  be  proper  to  toucli  it  lightly 'twice  a 
day  with  the  solid  nitrate  of  silver,  or  a  solution  of  one 
part  of  acid  nitrate  of  mercury  to  four  parts  of  water. 

The  constitat'ional  treatment  is  rigidly  antiphlogistic,  or 
tonic  and  supporting,  according  to  the  particular  nature  of 
the  case.  The  bowels  should  receive  early  attention  ;  the 
skin  be  kept  moist ;  and  pain  be  allayed  by  anodynes.  Per- 
fect recumbency  should  be  observed  until  the  parts  are  near- 
ly healed.  It  mercurj^  be  required,  the  best  forms  will  be 
calomel  and  blue  mass,  in  small  doses  twice  a  day,  with  a 
vigilant  eye  to  their  efiects,  ptyalism  being  sUidiously 
avoided  in  every  case. 

If  bubo  supervene,  the  treatment  must  be  prompt  and  ef- 
ficient, with  a  view  to  the  prevention  of  further  mischief. 
Recumbency,  the  topical  use  of  iodine  with  warm  water- 
dressing  medicated  with  lead  and  opium,  light  diet,  and  the 
antimonial  and  saline  mixture  constitute  the  most  appropri- 
ate measures.  If  matter  form,  an  early  and  free  incision  is 
made,  and  the  part  afterward  treated  as  a  common  sore,  the 
granulating  process  being  promoted  by  mild  means.  Mer- 
cury is  carefully  withhold,  at  all  events  in  the  early  stage  of 
the  disease. 

The  army  is  no  place  for  soldiers  laboring  under  seconda- 
ry or  tertiary  syphilis;  the  sooner  they  are  dismissed  from 
the  service  the  better,  especially  if  they  are  volunteers. 

Opldhalinia  is  one  of  the  annoyances  of  the  soldier's  life. 
Liable  to  bo  caused  by  cold,  it  is  capable  of  assuming  seve- 
ral varieties  of  form,  and  sometimes  i)revails  extensively  as 
an  epidemic.  The  granular  and  purulent,  in  particular,  arc 
to  be  feared,  as  they  frequently  destroy  the  sight,  and-  even 
the  eye,  in  a  few  days,  occasioning  intense  suffering^  To 
ascertain  the  condition  of  the  parts,  the  lids  must  a^ays 
be  gently  everted  with  a  prol)e  or  the  finger.  The  greatest 
cleanliness  should  be  observed  in  these  afl'ections  ;  the  pa- 
tients should,   if  possible,  be  sequestered,  at  all  events  not 


31ilUari/  Surgery.  61 

be  permitted  to  use  the  same  basins  and  towels  ;  the  lisfbt 
should  be  excluded  from  the  apartment ;  and  the  general 
and  local  treatment  should  eitlier  be  strictly  antiphlogistic 
or  of  a  mixed  character,  partly  antiphlogistic  and  partly 
stimulant.  The  applications  should  be  of  the  mildest  des- 
cription, especiall}'  those  intended  for  the  inflamed  surface. 
The  syringe  is  frequently  used  to  wash  away  the  secretions. 
Strong  collyria  generally  do  immense  harm  in  all  forms  and 
stages  of  ophthalmia.  Blood  may  be  taken  from  the  arm, 
or  by  cups  or  leeches  from  the  temples,  if  the  symptoms  are 
unusually  urgent  and  the  patient  plethoric.  In  rheumatic 
inflammation  of  the  eye,  colchicum  and  morphia,  given 
freely  at  bedtime,  will  be  of  immense  service. 

Whon  foreign  matter  gets  into  the  eye,  or  becomes  imbed- 
ded in  the  cornea,  speedy  removal  must  be  efl"ected,  and  the 
parts  afterward  treated  with  rest,  cold  or  tepid  bathing, 
gentle  aperients,  and  seclusion  from  light.  Particles  of 
steel  and  other  sharp  bodies  are  picked  out  with  the  point 
of  a  delicate  bistoury,  or  cataract  needle.  The  eflects  of 
lime  and  other  alkalies  are  ne'utralized  by  syringing  the  eye 
freely  with  a  weak  solution  of  vinegar ;  those  of  nitrate  of 
silver,  with  a  weak  solution  of  common  salt,  a  thorough 
coating  of  olive  oil  being  afterward  applied. 

Carbuncles,  boils,  and  abscesses,  which  ai^'e  of  frequent 
occurrence  in  army  practice,  demand  prompt  attention,  both 
on  ac,count  of  the  suffering  they  induce  and  the  disqualifi- 
cation they  may  entail  for  temporarj^  duty.  They  should 
be  opened  early  and  freely,  and  no  time  be  lost  in  amending 
the  general  health  by  gentle  mercurial  and  other  purgatives, 
alterants,  and  tonics,  particularly  quinine  and  iron.  The 
most  appropriate  topical  remedies  are  tincture  of  iodine  and 
warm  water-dressings. 

In  carbuncles  the  affected  structures,  after  free  division, 
will  generally  require  the  thorough  application  of  some 
cscharotic  or  detergent  stimulant,  as  Vienna  paste,  nitric 
acid,  nitrate  of  silver,  or  acid  nitrate  of  mercury. 

Frost-bite  is  extremely  common  among  soldiers  during  the 
cold,  wet  weather  of  winter.  Thousa'nds  of  the  French 
troops  perished  from  this  cause  in  Eussia,  during  Napole- 
on's retreat  from  ^loscow.  Frost-bite  was  very  prevalent 
among  tile  English  during  their  first  winter  in  the  Crimea, 
and  the  French  suffered  in  still  greater  numbers,  as  well  as 
more  severel3\  The  habit  which  the  men  had  of  sleeping 
in  their  wet  jjoots,  at  one  time  almost  universal,  contributed 


62  3Iilitary  tiurgery. 

greatly  to  its  production,  wet' and  cold  combined  diminish- 
ing the  circulation  and  vitalit}'  of  the  foet  and  toes.  On 
the  21st  of  January,  1855,  -when  the  thermometer  stood  at 
5°,  not  less  than  2500  cases  of  frost-bite  were  admitted  into 
the  French  ambulance,  and  of  these  800  died,  death  in 
many  liaving  no  doul)t  been  expedited  by  the  etfects  of 
erysipelas,  pyemia,  and  hospital  gangrene.  AVeak  and  in- 
temperate persons  are  most  apt  to  have  frost-bite  and  to 
perish  from  its  eifects. 

In  the  treatment,  in  incipient  cases,  cloths,  wrung  out  of 
cold  water  impregnated  with  a  little  spirits  of  camphor  or 
alcohol,  should  be  applied,  or  the  parts  be  covered  for  a  few 
minutes  with  snow,  or  immersed  in  cold  water.  On  no 
account  must  they  be  exposed  to  warmth,  either  moist  or 
dry.  Excessive  reaction  is  controlled  by  lead  and  lauda- 
num lotions,  or  dilute  tincture  of  iodine.  If  gangrene 
occurs,  the  ordinary  measures,  local  and  general,  are  indi- 
cated. All  rude  manipulation  in  dressing  the  injured  part 
greatly  aggravates  the  disease.  In  general,  spontaneous 
amputation  is  waited  for,  experience  having  shown  that 
operative  interference,  even  ^^'hen  the  partis  perfectly  Idack, 
and  attached  only  by  a  few  living  shreds,  is  extremely  pron  e 
to  be  productive  of  excessive  pain  and  constitutional  irrita- 
tion, often  proceeding  to  an  alarming  -extent. 

Among  the  great  evils,  both  of  civil  and  military  prac- 
tice, are  bed-sores,  which,  unless  the  greatest  possible  pre- 
caution be  used,  are  sure  to  arise  during  the  progress  of 
acute  diseases  and  of  severe  accidents,  necessitating  pro- 
tracted recumbency.  The  hips  and  sacral  region  are  their 
most  common  sites,  with  the  heel  in  cases  of  fractures  of 
the  leg.  The  earlier  symptoms  are  a  sense  of  prickling, 
as  if  the  part  were  I'ublicd  with  coarse  salt,  or  a  burning, 
itching  or  smarting  pain,  with  a  brownish  or  livid  discolo- 
ration of  the  skin,  and  slight  swelHng.  Then  gangrene 
ensues,  followed  by  horrible  suffering. 

To  prevent  these  sores,  which  often  prove  destructive  to 
life,  wlien  there  is  already  much  exhaustion  from  previous 
suffeiing,  the  posterior  surface  of  the  body  should  be  fre- 
quently examined,  particuhirly  if  the  patient  is  iji  a  state 
of  mental  torpor,  and  pains  taken  to  ward  off  pressure  by 
the  use  of  air  cushions  and  other  means.  The  parts  should 
be  sponged  several  times  a  day  with  some  alcoholic  lotion 
containing  alum,  or  painted  with  a  weak  solution  of  iodine. 
If  gangrene  or  ulceration  occurs,  a  yeast  or  port  wine  poul- 


unitary  Surgery.  63 

tice  is  used,  the  separation  of  the  slough  is  aided  with  the 
knife,  while  the  granulating  process  is  promoted  by  the 
usual  remedies. 

Ulcers  of  tlie  leg  are  causes  of  disqualification  in  enlist- 
ing, but  they  sometimes  occur  after  the  soldier  has  entered 
the  service,  from  fatigue,  injury,  or  undue  constriction  of 
the  limb.  However  induced,  they  should  be  managed  as 
any  other  forms  of  inflammation,  recumbency  with  eleva- 
tion of  tlie  affected  parts,  tepid  water-dressings,  a  restricted 
diet,  and  cooling  purgatives  constituting  the  most  import- 
ant elements  of  the  treatment.  When  tl)C  healing  process 
has  fairl}^  commenced,  the  leg  should  be  supported  with  the 
roller,  or  adhesive  strips. 

As  preventive  of  ulcers  of  the  legs,  the  limbs  should  be 
daily  washed  in  cold  water  with  Castile  soap,  and  no  soldier 
should  be  permitted  to  wear  garters. 


CHAPTER  X. 


MILITARY    HYGIENE. 


ISIuch  disease  and  suffering  maybe  prevented,  and  many 
lives  saved,  by  a  careful  observance  of  hygienic  regulations. 
There  is  no  question  whatever  that  immense  numbers  of 
soldiers  everywhere  foil  victims  to  their  recklessness. and 
the  indulgence  of  their  appetites  and  passions.  We  would 
not  advocate  too  much  restraint ;  men  are  but  men  every- 
where, and  soldiers  form  no  exception  to  the  general  law. 
The}',  like  civilians,  must  have  their  amusements  and  re- 
creations. The  bow  cannot  last  long,  if  kept  too  constant- 
ly and  too  tightly  on  the  stretch.  Occasional  relaxation  is 
indispensable  to  health. 

Indolence,  however,  should  never  be  countenanced  in  any 
army.  Its  demoralizing  effects,  and  its  influence  upon  the 
health  of  the  soldier,  have  been  noticed  and  commented 
upon  in  all  ages.  "The  etHcacy,"  says  an  eminent  military 
surgeon,  in  speaking  on  this  subject,  "of  due  attention  to 
the  occupation  of  the  mind  must  never  be  lost  sight  of. 
Many  illustrations  of  its  powerful  influence,  whether  for 
good  or  evil,  whether  in  resisting  or  accelerating  ihQ  in- 
roads of  disease,  may  be  found  both  in  ancient  and  in 
modern  times,  from  the  retreat  of  the  ten  thousand  Greeks 


64  Military  Surgery. 

under  Xcnophon  down  to  tlio  present  day.  It  may  be  ob- 
served tbat  disease  goes  liand  in  band  \vitb  indolence  and 
inactivity,  -vvbetber  of  body  or  of  mind;  and  tbat,  on  tlio 
contrary,  Avbere  tbe  minds  of  soldiers  are  agreeably  occu- 
pied, and  tlieir  bodies  cnerg'ctically  employed,  as  in'tbe  at- 
tainment or  pursuit  of  victory,  disease  is  kept  in  abeyance." 
It  Avns  tbe  observation  of  anotbcr  experienced  autbority  in 
military  medical  aflairs,  Mr.  Alcock,  tbat  "tbe  period  of 
tbe  smallest  loss  to  an  army  is  a  victorious  and  vigorously 
prosecuted  campaign,  witli  frequent  battles  and  mucli 
marcbing;"  an  assertioii  corroborative  of  tbe  facts,  long 
since  so  painfully  realized,  tbat  sickness,  bowever  induced, 
destroys  incomparably  more  soldiers  tban  tbe  sword  and 
tbe  musket. 

Xo  intemperance,  eitbcr  in  eating  or  drinking,  sbouldbe 
tolerated  in  an  army;  botb  are  demoralizing,  and  botli  pre- 
dispose to,  if  not  actually  provoV:e,  disease.  Alcobolic  li- 
quors sbould  not  be  permitted  to  be  used  except  as  medi- 
cine, and  tben  only  under  tbe  immediate  direction  of  tbe 
medical  officer.  The  ordinary  drink  and  food  sbould  be 
selected  witb  special  reference  to  tbeir  bealtbful  properties. 
Tbe  use  of  bad  water,  even  for  a  sbort  time,  is  invariably 
productive  of  miscbief.  Tlie  tea  and  cottee  sbould  be  of 
good  quality,  and  well  prepared,  to  preserve  tbeir  agreeable 
flavor  and  tbeir  sootbing  and  refresbing  effects.  Lager 
beer,  ale,  and  porter,  if  sound,  are  botb  nourisbing  and 
wbolesome.  if  consumed  witbin  judicious  limits. 

Tbe  practice  of  allowing  soldiers  spiritous  liquors,  as  a 
portion  of  tbeir  daily  rations,  bas,  I  believe,  been  pretty 
gencrall}^,  if  not  entirely,  abandoned  in  tbe  European  ser- 
vice. Its  injurious  cifccts  upon  tbe  bealtb  and  morals  of 
troops  bave  long  been  deprecated.  In  tbe  Britisb  army  in 
India,  tbe  use  of  alcobolic  liquors  was,  at  one  time,  univer- 
sal, on  tbe  supposition  tbat  it  bad  a  tendency  to  counteract 
tbe  depressing  influences  of  a  tropical  climate ;  tbe  men 
took  tbeir  spirits  regularly  before  breakfast,  and  not  un- 
frequcntly  several  times  during  tbe  day,  espcciall}'  if  on 
active  duty;  but  it  ^vas  soon  found  tbat  it  produced  quite  a 
contrary  impression,  causing  insteadof  preventing  debility, 
and  aflording  a  temptation  to  general  drunkenness,  wliicb 
%vas  followed  by  insubordination  and  crime.  The  result 
was  tbat  tbe  government  abolisbed  tbe  alcobolic  ration  sys- 
tem altogetber,  substituting  coifec  and  tea,  wbicb  are  now 
regularly  served  once,  and  often  twice  a  day. 


Military  Surgery.  65 

The  condition  of  the  13th  Regiment  of  Light  Infantry, 
stationed  at  Jcllalabad,  during  tlic  Late  insurrection  in  India, 
affords  a  happy  illustration  of  the  salutary  effects  of  absti- 
nence from  spiritous  liquors.  While  the  siege  was  pro- 
gressing, the  men,  during  a  period  of  live  months,  were 
entirel}'  debarred  from  drinking,  and  yet  their  health  and 
courage  were  most  excellent.  As  soon,  however,  as  the 
garrison  was  relieved,  and  they  began  to  indulge  in  spirits, 
mau}^  of  them  in  a  short  time  became  sick  and  riotous. 
The  experience  of  Major-General  Wylie,  of  the  Bombay 
army,  was  precise]}^  similar.  When  the  soldiers  under  his 
command  were  quartered  in  districts  where  no  liquor  could 
be  obtained,  their  health,  discipline,  and  morals  were  all 
that  could  be  desired  ;  whereas,  under  opposite  circumstan- 
ces, insubordination  and  disease  prevailed  to  a  frightful 
extent. 

During  the  Crimean  war,  coffee  and  tea  were  found  to  be 
eminently  wnolesome  and  invigorating,  enabling  the  troops 
to  sustain  fatigue  and  to  resist  disease.  When  the  men 
were  in  the  trenches,  and  could  not  obtain  their  usual  sup- 
plies of  these  articles,  they  became  languid,  and  suffered 
trom  dysentery  and  diarrhoea.  To  produce  their  peculiar 
sustaining  and  exhilarating  effects,  coffee  and  tea  should  be 
taken  hot  and  moderately  strong,  with  sugar,  if  not  also 
with  cream. 

Fresh  meats  are  always  prefera1)le  to  salt,  though  good 
ham  and  smoked  beef  may  be  taken  once  a  day  with  ad- 
vantage as  an  agreeable  change.  Fresh  fish  are  alwa3's  ac- 
ceptable. Pickled  pork  and  beef  are  fai  from  being  good 
articles  as  a  portion  of  the  daily  rations.  The  frequent  use 
of  fresh  vegetables  is  indispensable  to  the  health  of  the 
soldiery.  Kipe  fruits  are  nearly  equally  so.  Without  a 
proper  admixture  of  this  kind,  dyspepsia,  bowel  complaints, 
and  scurvy  will,  sooner  or  later,  inevitably  ensue  ;  and  woe 
to  the  man  that  is  assailed  by  them !  The  acids  and  other 
properties  contained  in  these  substances  are  indispensable 
to  the  healthy  condition  of  the  blood  and  solids,  and  the 
importance  of  such  a  diet  cannot  be  too  deeply  or  too  fre- 
quently impressed  upon  the  attention  of  every  commissa- 
riat. Potatoes,  rice,  hominy,  beans,  peas,  beets,  spinach, 
lettuce,  asparagus,  radishes,  horse-radish,  water-cresses, 
dried  peaches  and  apples,  and  the  different  kinds  of  fruits 
as  they  come  into  season,  should  be  constantly  on  hand. 
Soups,  both  animal  and  vegetable,  are  generally  grateful  to 


GG  Military  Surgery. 

the  palate,  as  ^vell  as  useful  to  tlic  system,  aud  should  be 
used  wheuever  the  occasion  is  favorable  for  their  ju-epara- 
tion. 

Ejtecs,  butter,  milk,  and  butter-milk  should  ]>e  freely  in- 
dultied  in  whenever  they  can  be  procured.  Serious  disease 
is  often  engendered  by  bad  bread  and  biscuit,  and  it  should 
therefore  be  made  a  part  of  the  duty  of  every  medical  offi- 
cer to  see  that  no  articles  of  this  kind  are  brought  into 
camp. 

When  in  the  camp  or  barracks,  the  soldier  should  take 
his  meals  with  the  same  regularity  as  the  ordinary  citizen 
at  his  home.  Keglect  of  this  precaution  must  necessarily 
lead  to  great  bodily  inconvenience,  and,  if  long  persisted 
in,  may  ultimately  lead  to  serious  disease,  especially  dys- 
pepsia aud  other  disorders  of  the  digestive  apparatus.  lie 
should  not  disregard  regalarity  even  with  respect  to  his 
alvine  evacuations ;  for  there  are  few  things  more  conducive 
to  the  yn-eservation  of  the  health. 

The  soldier's  dress  should  be  in  strict  conformity  with  the 
season  of  the  year  and  the  vicissitudes  of  the  weather.  lie 
should,  at  no  time,  be  either  too  hot  or  too  cold,  but  always 
comfortable,  changing  his  apparel  with  the  alterations  of 
the  temperature.  Flannel  should  be  worn  next  the  surface 
both  winter  and  summer.  The  shoes  must  be  thick  and 
warm,  with  broad  soles;  and  woolen  stockings  will  be  more 
comfortable,  especiall}^  when  the  troops  are  marching,  than 
cotton.  A  thin  woolen  cap-cover,  found  so  useful  in  India, 
will  protect  the  neck  from  the  hot  sun,  and  an  oil-silk  cap- 
cover,  from  the  rain.  In  very  wet  weather  the  shoulders 
might  be  defended  with  a  cape  of  oil-cloth. 

Frequent  abluiions  will  largely  contribute  to  the  comfort 
of  the  soldier  and  the  preservation  of  his  health.  They 
should  be  performed  at  least  once  a  day,  the  best  time  be- 
in.o;  late  in  the  afternoon  or  in  the  evening  just  before  re- 
tiring. The  feet,  in  particular,  should  be  often  washed, 
especially  in  marching,  for  reasons  which  need  not  be  dwelt 
upon  here.  The  under-shirt  should  be  changed  every  night, 
and  frequently  washed,  to  promote  the  healthy  state  of  the 
skin. 

Exposure  to  the  hot  sun,  to  cold  and  wet,  must  alike  be 
avoided.  Sojourning  in  malarious  regions  will  be  certain 
to  be  punished  by  an  attack  of  neuralgia  or  intermittent 
fever. 

All  offals  should  be  promptly  removed  from  the  camp, 


Military  ^uryery.  67 

and  carried  to  a  distance  of  several  miles,  or  be  well  buried. 

The  privies  should  be  in  the  most  favorable  location  as  it 
respects  ventilation,  and  be  closed  at  least  every  three  or 
four  days  ;  or,  what  is  worthy  of  consideration,  every  man 
shoukl  be  compelled  to  bury  his  alvine  excretions,  as  was 
the  custom,  in  time  of  war,  among  the  ancient  Hebrews, 
each  man  being  obliged  to  carry  a  paddle  for  that  purpose. 
The  emanations  from  these  sources  cannot  receive  too  much 
attention,  especially  when  large  masses  of  men  are  crowded 
together,  as  they  arc  then  extremely  prone  to  induce  dis- 
ease. 

Finally  the  medical  officer  should  make  it  his  special 
duty  to  see  that  every  recruit  is  vaccinated,  or,  if  the  opera- 
tion was  performed  prior  to  his  enlistment,  at  a  diataut 
period,  matter  should  again  be  inserted,  experience  having 
shown  that  the  eftects  of  the  virus  are,  in  time,  in  many 
instances,  totally  eradicated  from  the  system.  In  most  of 
the  European  armies  revaccination  is  extensively  practiced; 
and  it  is  asserted  by  Stromeyer  that  during  the  Schleswig- 
Holstein  war,  on  an  average,  ^38  operations  out  of  1000 
were  successful. 

It  is  impossible  to  bestow  too  much  care  and  attention 
upon  the  selection  of  the  camp  ground,  and  the  arrange- 
ment of  the  tents,  as  a  vast  deal  of  the  comfort  and  health 
of  the  soldiers  must  necessarily  depend  npon  them.  The 
following  judicious  remarks  upon  this  subject  are  from  the 
pen  of  an  eminent  military  surgeon,  thelateDr.  Ballinerall, 
wdio  served  in  various  campaigns,  and  who  was  for  many 
years,  as  stated  elsewhere,  Professor  of  Military  Surgery  in 
the  University  of  Edinburgh. 

"A  camp,"  says  Ballingall,  "is  most  advantageously  sit- 
uated on  a  gentle  declivity,  on  a  dry  soil,  and  in  the  vicinity 
of  a  running  stream.  In  order  to  ascertain  the  state  of  the 
ground  it  may  sometimes  be  necessary  to  dig  into  it  to  some 
extent ;  for,  although  apparently  dry  on  the  surface,  it  may 
be  found  sufficiently  wet  at  the  depth  of  a  few  feet ;  and  if 
so,  ought,  if  possible,  to  be  changed,  particularly  if  an  en- 
campment is  to  be  stationary.  A  camp  should  never  be 
formed  on  ground  recently  occupied,  nor  on  a  field  of  bat- 
tle where  much  carnage  has  recently  occurred.  Many  fa- 
vorable spots  are  to  be  found  on  the  banks  of  rivers,  which, 
perhaps,  upon  the  wdiole,  aflbrd  the  most  eligible  sites.  We 
must  yet  bear  in  mind  that,  when  the  banks  of  the  rivers 
are  low,  or  the  countiy  subject  to  periodical  rains  or  sudden 


68  Military  Surgery. 

iuuiulatioiis  from  the  melting  of  snow  on  contiguous  moun- 
tains, there  may  be  a  very  serious  danger  from  this  cause. 
Against  the  danger  of  such  a  position,  we  arc  cautioned  in 
Mezerey's  'Medccine  d'Arraee,'  which  states  a  case  in  which 
the  Austrian  army  lost  500  men  and  200  horse  from  a  sud- 
den inundation  of  this  kind." 

When  damp  ground  or  a  low  situation  is  unavoidable,  it 
should  be  abandoned  as  soon  as  possible  for  a  better,  and, 
in  the  meantime,  the  greatest  care  shoilld  be  taken  to  pro- 
tect the  soldiers  from  damp  or  wet  with  straw  or  other  suit- 
able means. 

An  army  has  been  known  to  suiier  severely  from  disease 
contracted  in  a  malarious  region.  Against  such  a  calamity 
useful  information  may  often  be  elicited  from  the  people  of 
the  neighborhood,  especially  physicians  conversant  with 
insalubrious  sites. 

AVhcn  an  army  is  obliged  to  remain  for  a  long  time  sta- 
tionary, an  occasional  change  of  camp  will  be  greatly  con- 
ducive to  health,  although  such  change  should  involve  a 
o-ood  deal  of  labor  and  temporary  inconvenience.  A  camp 
under  such  circumstances  should,  at  all  events,  be  frequently 
ventilated,  and  kept  constantly  clean,  a  jaire  atmosphere 
being  of  paramount  importance  to  health  and  comfort.  It 
may  often  be  ditHcult  to  do  this,  but  it  must,  nevertheless, 
be  done;  the  welfare  of  the  service  absolutely  demands  it, 
and  no  medical  officer  honestly  performs  his  duty  unless  he 
interests  himself  personally  in  these  matters.  "The  most 
obvious  and  perfect  way,"  says  Ballingall,  "of  thoroughly 
airing  the  tents  is  by  shifting  them  occasionally,  and  ex- 
posing the  straw,  blankets,  and  soldier's  clothing  to  the 
open  air;  the  necessity  of  Irequently  changing  tlie  straw, 
and  enforcing  cleanliness  in  camp  in  every  possible  way, 
are  circumstances  too  obvious  to  require  any  cttbrt  of  rea- 
sonino-  to  enforce.  With  this  view  the  slaughtering  of 
cattle,  and  everything  likely  to  create  noxious  or  putrid 
effluvia,  ought  to  be  conducted  without  the  camp,  and  on 
the  side  of  "it  op[)Osito  to  that  from  which  the  wind  gene- 
rally blows."  The  demoralizing  influence  of  a  camp  life  is 
well  known,  and  I  am  convinced  that  there  is  nothing  so 
well  calculated  to  counteract  this  influence  as  rigid  discip- 
line, reasonable  activity  of  mind  and  body,  strict  temper- 
ance, both  in  eating  and  drinking,  and  frequent  religious 
worship.  Every  regiment  should  have  its  chaplains,  not 
lees  than  its  medical  officers,  not  only  with  a  view  of  re- 


Military  Surgery.  '  69 

straining  vice  and  promoting  moralit}',  but  of  affording  to 
the  poor  soldier,  away  from  Lome  and  friends,  in  the  hour 
of  his  mortal  extremity,  those  consolations  which  the  min- 
ister of  the  gospel  alone  knows  how  to  impart.  The  miti- 
gation of  the  horrors  and  miseries  of  war,  not  less  than  the 
tendencies  of  the  age  in  which  we  live,  absolutely  demand 
such  a  provision. 


CHAPTER  XL 

DISQUALIFYING     DISEASES. 

Troops,  whether  regulars  or  volunteers,  should  include 
no  men  that  are  not  perfectly  qualitied,  both  physically  and 
mentally,  for  the  liardships  of  the  public  service.  They 
should,  in  a  word,  be  perfectly  sound,  or,  what  is  the  same 
thing,  free  from  all  defects,  congenital  or  acquired.  It  is 
for  this  reason  that  they  are  always  subjected  to  a  most 
thorough  examination  by  the  recruiting  or  regimental  sur- 
geon. This  examination  is,  as  a  general  rule,  a  great  deal 
more  rigid  in  the  regular  than  in  the  volunteer  service.  In 
the  former,  the  regulations  are  such  that,  if  the  recruit  is 
not  found  to  be  sound  after  he  has  been  inspected  by  the 
regular  army  surgeon,  the  expense  incident  to  his  enlist- 
ment and  transportation  foils  upon  the  medical  otlicer  who 
committed  the  oversight. 

An  examination  of  the  kind  here  mentioned  demands 
both  time,  patience,  and  skill.  In  order  to  make  it  thorough, 
the  candidate  must  be  completely  stripped,  so  that  if  any 
disease  or  defect  in  the  exterior  of  the  body  exist  it  may  be 
at  once  rendered  apparent.  The  examination,  however, 
must  not  be  limited  to  the  exterior  ;  it  must  embrace  also 
the  interior.  The  disqualifying  affections  may  be  arranged 
according  to  the  organs  and  regions  in  which  they  are 
seated,  under  separate  heads : — 

1.  The  eye  and  ear.  2.  The  brain,  as  the  seat  of  intel- 
lect. 3.  The  lungs  and  heart.  4.  The  stomach,  bowels, 
anus,  liver,  and  spleen.  5.  The  kidneys,  bladder,  and  ure- 
thra. 6.  The  testicles.  7.  The  exterior  of  the  abdomen. 
8.  The  limbs,  including  the  joints. 

The  diseases  which  unfit  a  man  for  military  service  are 
defects  of  sight,    of  hearing,  and  of  speech;  weakness  of 
intellect;    paralvsis ;    epilepsy;    hernia;    hydrocele;   vari- 
5 


70  Military  Surgery. 

cocele ;  imperfect  dcvelopnieiit  or  absence  of  the  testes; 
hemorrhoic's,  anal  fistule,  and  tissurc  of  the  anus;  unusual 
protuberance  of  the  abdomen  ;  organic  lesion  of  the  internal 
organs;  large  tumors;  aneurism  ;  varix  of  the  extremities; 
ulcers,  or  large  scars  indicative  of  their  former  existence; 
bad  corns;  bunions;  overlapping  toes  ;  tlatfootedness ;  de- 
formity of  the  hands  and  fingers;  contractions  from  burns 
or  other  causes;  badly  united  fractures;  unreduced  dislo- 
cations; diseased  joints;  loss  of  the  incisor  and  caninctceth; 
serious  disfigurement  of  the  features;  sjiinal  curvature;  ill- 
formed  shoulders;  habits  of  intemperance:  diminutive 
stature  or  excessive  overgrowth. 

In  the  regular  army  no  man  is  enlisted  under  the  age  of 
eighteen  or  over  that  of  forty-five.  In  the  volunteer  service, 
similar  regulations  obtain,  although  they  are  not  so  rigidly 
enforced. 

Recruiting  surgeons,  after  having  examined  a  candidate 
for  enlistment,  arc  obliged  to  certify,  on  honor,  that  they 
consider  him,  in  their  opinion,  to  be  free  from  all  bodily 
defects,  and  mental  infirmity,  which  would,  in  any  way, 
disqualify  him  for  performing  the  duties  of  a  soldier. 

When  men  become  disqualified  for  service,  in  conse- 
quence of  disease  or  accident,  a  surgeon's  certificate  is  also 
required,  in  order  to  aid  them  afterward  in  procuring  a  pen- 
sion and  exemption  from  ordinary  military  duties.  The 
afiections  which  may  justify  a  soldier  in  applying  for  a  re- 
lease from  further  service  are  oiganic  visceral  lesions,  deaf- 
ness, blindness,  mental  imbecility,  lameness,  large  herni?e, 
and  such  mutilations  as  interfere  with  the  proper  handling 
of  the  sword  and  musket. 


CHAPTER  XII. 

FEIGNED    DISEASES. 

Soldiers,  influenced  by  a  desire  to  quit  the  service,  to  re- 
visit their  homes,  or  evade  active  duty,  will  not  hesitate,  at 
times,  to  play  the  part  of  impostors,  feigning  diseases,  or 
even  inflicting  upon  themselves  more  or  less  serious  inju- 
ries, with  the  hope  of  accomplishing  their  designs.  This 
deception,  technically  called  malingering,  would  be  of 
comparatively  little  consequence  if  it  were  always,  or  even 
generally,  confined  to  a  few  members  of  a  regiment ;   but 


Military  Surgery,  ?! 

wlien  it  is  remembered  that  it  is  liable  to  become  epidemic, 
spreading  from  individual  to  individual,  it  assumes  a  deep 
importance,  well  calculated  to  arouse  the  attention  both  of 
the  medical  officer  and  of  the  military  commander.  Its 
effects,  then,  become  eminently  demoralizing  to  the  service, 
which,  if  proper  care  be  not  employed  to  detect  and  punish 
it,  might  seriously  suffer,  especiall}-  when  such  an  outbreak 
occurs  on  the  eve  of  a  battle.  Great  ingenuity  is  often 
displayed  by  mnlingerers,  requiring  no  little  vigilance  and 
skill  on  the  part  of  the  surgeon  for  \'-%  successful  exposure, 
and  yet  it  is  not  less  necessary  for  his  own  credit  than  for 
the  honor  of  the  service  that  he  should  not  permit  himself 
to  be  deceived. 

The  number  of  diseases,  imitated  by  this  class  of  dis- 
semblers, is  surprisingly  great,  and  there  is  also  quite  a  list 
of  self-inflicted  injuries.  Among  the  former  are  various 
mental  diseases,  as  mania  and  imbecility;  deafness;  amau- 
rosis ;  epilepsy;  paral^'sis  ;  hrematemesis  ;  htemoptysis  ; 
gastritis;  dysentery  and  diarrhcca;  affections  of  the  heart; 
rheumatism  ;  lumbago ;  wry-neck ;  contractions  of  the 
joints  ;  incontinence  of  urine;  bloody  urine  ;  and  stone  in 
the  bladder :  among  the  latter  opthalmia,  opacity  of  the 
cornea,  oedema  of  the  limbs,  wounds,  and  amputations  of 
the  fingers.  ^ 

Space  will  not  permit  me  to  enter  into  any  details  re- 
specting this  important  subject.  I  shall,  therefore,  content 
myselt  with  a  presentation  of  such  facts  as  may  be  sup- 
posed to  be  of  special  practical  interest. 

First  of  all,  the  medical  officer  should  weigh  w^ell  in  his 
own  mind  the  nature  of  the  disease  for  which  a  soldier  ap- 
plies for  a  certificate  of  discharge,  or  inability  to  perform 
duty.  If  the  case  is  one  of  recent  standing,  il  will  be  well 
not  to  come  to  too  hasty  a  conclusion  as  to  its  diagnosis ;  it 
should  be  examined  and  re-examined  before  any  definite 
opinion  is  given.  Day  by  day  facts  may  be  develojied, 
revealing  the  true  character  of  the  affection.  If  the  patient 
is  really  sick,  or  affected  with  someserious  chronic  disorder, 
his  general  appearance  will  hardly  fail  to  afford  some  evi- 
dence of  its  existence.  The  pallor  of  the  countenance,  the 
functional  disturbance  of  the  suffering  organ,  the  bodily 
prostration,  the  want  of  appetite,  and  the  gradual  emacia- 
tion will  almost  unerringly  point  to  the  nature  and  scat  of 
the  disease.  When,  on  the  other  hand,  the  malady  is 
simulated,  all,  or  nearly  all,  the  usual  phenomena  of  disease 


'72  Military  Surgery. 

will  be  absent.  Irapostoi-s,  moreover,  are  generally  very 
zealous  in  talkinp;  about  their  disorders,  or  in  obtruding 
them  upon  the  notice  of  their  surgeons,  whereas  those  who 
are  really  sick  and  suftbring  make  comparatively  little  com- 
plaint. A  malingerer  may  often  be  detected  by  carefully 
watching  his  movements,  coming  suddenly  upon  him  when 
he  is  asleep,  or  when  his  attention  is  directed  to  some  one 
else,  tickling  his  foot  when  he  feis^us  paralysis,  or  pricking 
his  back  when  he  pretends  to  be  laboring  under  lumbago. 
Sometimes  a  determined  threat  will  pn)mptly  restore  him 
to  a  sense  of  his  duty,  as  the  application  of  the  actual 
cautery  in  incontinence  of  urine,  rheumatism  of  the  joints, 
or  mcp-tal  indDccility.  Xow  and  then  the  exhibition,  in 
rapidly  repeated  doses,  of  a  nauseous  draught,  answers  the 
purpose.  Whatever  expedients  be  employed  the  surgeon 
cannot  exercise  too  ranch  address,  otherwise  he  will  l)e 
almost  sure  to  be  baffled. 

Mental  alienation,  or  mania,  unless  the  result  of  inebria- 
tion and  of  acute  disease,  generally  comes  on  gradually, 
being  preceded  by  a  marked  change  in  the  moral  character 
of  the  individual,  loss  of  appetite  and  sleep,  and  other 
evidences  of  general  disorder. 

(ienuine  deafness  is  also  gradual  in  its  approaches,  and, 
when  fully  established,  is  it\ variably  attended  by  a  peculiar 
listless  state  of  the  countenance  with  more  or  less  change 
of  the  voice.  Before  a  final  decision  is  given,  a  careful 
inspection  of  the  ears  should  be  made,  to  ascertain  whether 
there  is  any  obstruction  or  appearance  of  matter.  The  un- 
expected discharge  of  a  pistol,  in  a  case  of  feigned  deafness, 
might  suddenly  decide  the  diagnosis. 

Amaurosis  may  be  simulated  by  the  internal  use  ot  bella- 
donna, or  by  the  direct  a})plicMtion  of  this  article  to  the  eye, 
causing  dilatation  and  immobility  of  the  pupil.  These 
effects  are  often  accompanied  by  unnatural  vascularity  of 
the  conjunctiva,  and  they  generally  disappear  spontaneously 
in  a  few  days.  h\  genuine  amaurosis,  too,  there  is  always 
a  dilated  condition  of  the  vessels  of  the  e^e. 

Feigned  epileps)/  differs  IVom  the  real  in  the  absence  ot 
lividity  of  the  countenance,  the  want  of  troth  at  the  mouth, 
and  the  partial  character  of  the  convulsions.  The  pupil 
does  not  contract,  as  in  the  genuine  disease,  the  general 
sensibility  is  unimpaired,  the  tongue  is  not  injured,  the 
nails  are  not  discolored,  the  hand,  if  opened,  is  again  iirmh' 
shut,  and  the  individual    often   watches  with  his   ey(;  the 


Military  Surgery. 

impression  the  attack  is  making  upon  the  by-standers.  The 
application  of  a  heated  case-knife,  or  of  a  cloth  wrung"  out 
of  hot  water,  often  speedily  reveals  the  imposition. 

Paralysis  is  ireqiiently  imitated,  but  is  generally  easily 
detected,  simply  by  watching  the  patient,  tickling  his  teet 
when  he  is  asleep,  or  threatening  him  with  the  hot  iron. 
The  disease,  when  it  attacks  the  lower  extremity,  is  nearly 
always  caused  by  apoplexy,  and  is  then  generally  associated 
with  mental  weakness  and  ditHculty  of  articulation.  Partial 
paralysis  of  the  upper  extremity  is  freciuently  induced  by 
lying  upon  the  arm,  by  suppression  of  the  cutaneous  per- 
spiration, and  disease  of  the  spinal  cord. 

Ilccmatemcsis  may  be  simulated  by  swallowing  blood,  or 
an  infusion  of  logwood,  and  ejecting  the  tiuid  afterward  by 
vomiting.  It  should  be  recollected  that  the  real  disease  is 
almost  invariably  connected  with  serious  organic  lesion,  as 
ulceration  of  the  stomach,  induration  and  enlargement  of 
the  liver,  or  visceral  obstruction,  and  that  the  patient,  con- 
sequently, will  exhibit  all  the  characteristic  of  a  sick  jier- 
son. 

Soldiers  sometimes  countertieit  lucrnop lysis,  by  cutting  the 
gums,  or  chewing  substances  impregnated  with  coloring 
matter.  A  case  is  related  by  Guthrie,  in  which  a  man,  for 
this  purpose,  swallowed  a  piece  of  cork  full  of  pins.  The 
immediate  eii'ect  was  haemoptysis,  and  the  remote  one  death 
by  wounding  the  carotid  artery. 

Gastrins  maj-  be  simulated  by  spontaneous  vomiting,  a 
faculty  possessed  by  some  persons,  and  by  pretended  pain 
in  the  epigastric  region.  The  attack  in  general  speedily 
yields  to  a  large  sinapism  and  a  brisk  emetic. 

Dysentery  and  diarrhxa  are  occasionall}^  teigned  by  ex- 
citing, artificially,  irritation  of  the  rectum,  by  mixing  blood 
with  the  alvine  evacuations,  or  by  borrowing  the  discharges 
of  persons  actually  atfected  with  these  diseases.  In  gen- 
uine dysentery  and  diarrhcra  there  are  always  well-marked 
constitutional  phenomena,  which  are  of  course  absent  in 
the  spurious.  Careful  watching  of  the  patient  and  com- 
pelling him  to  use  a  close  stool  will  soon  remove  any  doubt 
that  may  exist  respecting  the  nature  of  the  case. 

Disease  of  the  hearU  in  the  form  of  palpitation,  may,  it  is 
said,  be  produced  by  the  use  of  hellebore.  Mr.  Hutchinson, 
of  England,  refers  to  aii  epidemic  of  this  kind  among  the 
members  of  the  Marine  Artillery.  Organic  cardiac  disease 
could  easily  qe  detected  with  the  stethoscope. 


74  Military  Siirf/en/. 

Rheumatism  being-  a  very  common  disease  among  soldiers' 
is  often  counterfeited  ;  but  the  cheat  is  of  easy  detection 
when  it  is  recollected  that  the  real  affection,  especially  the 
acute  torni.  is  attended  with  more  or  le-«s  swellinor  and 
constitutional  disturbance. 

When  lumbago  is  made  the  subject  of  deception,  the  at- 
tack seldom  long  withstands  the  application  of  rash  reme- 
dies, or  the  threatened  use,  if  speedy  relief  do  not  arise,  of 
the  hot  iron. 

Contraction  of  ihc  joints^  a  not  unfrequent  source  of  im- 
j)o.sition,  is  easily  detected  by  the  use  of  ana-'stlietics.  or 
simply  by  pricking  the  parts  suddenly  with  a  needle,  when 
th  ;  jiatlent  is  off  his  guard. 

When  wry-neck  is  simulated,  both  the  sterno-cleido-mas- 
to"d  muscles  are  rendered  rigid  by  the  effort  at  deception; 
"whcrjas  in  the  real  disease  the  contraction  is  confined  to 
one  side. 

Incontinence  of  urine,  bloody  nrine,  and  stone  in  the  blad- 
der have  all  been  simulated  by  designing  soldiers.  The 
former  is  said  to  be  at  times  epidemic,  and  then  its  detec- 
tion is  of  course  easy,  as  the  ordinary  disease  never  assumes 
such  a  cliaracter.  Harsh  remedies  are  the  best  means  of 
relief.  Ballingall  states  that  fictitious  cases  of  incontinence 
have  been  successfully  treated  by  the  cold  bath,  by  pre- 
scribing a  few  lashes  on  the  loins,  -wiih  the  avowed  object 
of  strengthening  the  parts.  In  the  Austrian  army  the 
impostor  is  obliged  to  do  duty  with  a  urinal. 

Bloodii  urine  has  been  provoked  by  injecting  blood  into 
the  bladder,  and  by  scaritying  the  urethra. 

Calculus  h  almost  unknowi\  among  soldiers;  it  is  some- 
times attempted  to  be  counterfeited  by  scrai)ing  the  walls 
and  throwing  the  lime  into  the  urinal.  When  stone  actually 
exists,  the  sound  will  generally  promjitly  detect  it. 

►^elf-itillieted  iujuyies  of  various  kinds  are  restored  to  for 
the  pur[»ose  of  dece[)tion.  Thus  malingerers  often  provoke 
iiiliammation  of  the  eye  and  temporary  opacity  of  the  cor- 
nea by  means  of  corrosive  sublimate,  lime,  tobacco,  nitrate 
of  silver,  and  other  irritants.  A  great  number  of  men  have 
bc(Mi  known  to  suffer  from  this  clause  at  the  same  time,  as 
if  the  disease  was  an  epidemic.  Ulcers  of  the  legs  are  pro- 
duced by  pricking  the  skin  with  pins  or  needles,  frictions 
with  sand,  or  caustic  applications.  CEdema  of  the  limbs 
may  be  excited  by  tight  ligatures;  disease  of  the  scrotum 
and  testicle,  by  inflation  of  the  parts   with  air.     All  such 


Military  Suryery.  75 

tricks  arc  usually  readily  detectected  by  the  medical  officer 
aud  his  assistants. 

Self-mutilation  sometimes  amounts  to  the  destruction  ol 
an  eye,  an  entire  fini!:er,  or  even  the  greater  portion  of  the 
hand.  Occasionally  it  is  limited  to  slight  wounds,  and  the 
imposition  may  then  be  practiced  on  an  extensive  scale,  as 
was  the  case  in  the  French  army  at  the  battles  of  Lutzen 
and  Bautzen,  in  which  nearly  8000  soldiers  were  slightly 
injured  in  the  hand,  causing  the  belief  that  the  wounds  had 
been  voluntarily  inflicted. 


CHAPTER  Xm. 

MEDICAL,  SURGICAL,    AND   DIETETIC  FORMULAE. 

Under  this  head  I  propose  to  notice  such  tV.rnnilas,  or  medi- 
cal, surgical,   and  dietetic   preparations,  as  have  been   found 
serviceable  in  my  own  practice,  or  in  the  practice  of  others. 
1 , — General  Reiaedies. 
Among  the  more  %\\\\\>\(ypiir(jathies  may  be  mentioned  the 
following:  all  drastic  articles  should,  if  possible,  be  excluded 
from  the  prescriptions  of  the  military  surgeon: — 
R;. — Massne  ex  Hydrargy,  gr.  x  ; 
Pulv.  Ipecac,  gr.  i, 
M.  ft.  pil.  ii.         " 
A  mild  laxative  in  dyspepsia  and  disorders  of  the  stomach  and 
liver. 

R. — Extr.  Colocynth.  c ; 
Mass;\i  ex  Hydrargy. 
Pulv.  Rhei.  v.  Jalapa?,  aa  gr.  x  ; 
Ant.  et  Potassse  Tart.  gr.  t 
M.  ft.  pil.  V. 
An  active,  antibilious  ])tirgative,  from  three  to  tive  being  an 
ordinary  dose.     Calomel  may  be  substituted  for  the  blue  mass, 
if  there  is  much  disorder  of  the  liver  and  secretions. 

The  safest  emetics  are  ipecacuanha,  infusion  of  eupatoriuin 
perfoliatum,  and  mustard  and  common  salt,  an  even  table- 
spoonful  of  each  to  half  a  pint  of  tepid  water,  one-half  to  be 
taken  at  once,  the  remainder,  if  necessary,  in  tifteen  minutes. 
Sulphate  of  copper  or  zinc  will  afford  the  most  prompt,  emetic 
etiect  in  case  ol'  great  urgency,  as  in  poisoning. 

The  following  formula  will  be  found  very  servicable  in  the 
earlier  stages  of  most  inflammatory  aftections,  especially  the 


70  Military  ^urjm/. 

ciitanoons,  articular,   and  traumatic,  unaccompanied  1)v  dis- 
ease of  tlie  alimentary  canal  : 
R. — Ant.  et  Potass.  Tart.  gr.  iss  ; 

MagnesiiP  Sulph.  .^i  ; 

Morphife  Sulph.  gr,  ss; 

Saccli.  Albi.  5ii- 

AquiB  Dcstil.  5vi.  M. 
This  is  the  antimonial  and  saline  mixture,  of  which  repeated 
mention  occurs  in  the  jirecediui?  pages,  and  ^vllich  I  am  in  tlu' 
daily  habit  of  prescribing  in  my  surgical  as  well  as  medical 
j)ractice.  It  may  be  rendered  depressant  by  the  addition,  to 
each  dose, — which  is  half  an  ounce,  repeated  every  two  or 
tiiree  hours, — of  from  three  to  eight  drops  of  the  tincture  of 
veratrum  viride;  anodyne,  or  diaphoretic,  by  laudanum,  or 
morj)hia;  anti-periodic,  by  (p.iinine;  ani!-g.>no;'rh(eal,  by 
co[)aiba,  gum-arabic  being  used,  in  the  latter  case,  as  one  of 
the  ingredients;  and  anti-rheunuitic,  by  colchieum.  If  qui- 
nine  be  used,  the  addition  of  aromatic  sulphuric  acid  will  be 
required,  which  is  also  an  excellent  solvent  of  the  salts 
li. — Vini  Colchici  Sem.  5i ; 

Morphine  Sulph.  gr.  ss  ; 

Potassae  Carbon,  gr.  x ; 

Aqure  Destil.  .5ss.     M. 
In  rheunuitic  and  gouty  affections,  taken  at  bedtime,  and  fol- 
lowed by  a  mild  aperient  next  morning. 

The  following  will  be  found  to  be   pleasant   aiul  eillcient 
diaphoretics : — 

1^. — Spirit.  Mindereri,  Siv; 

Sp.  ^'Ether.  Xitrici.  5ii ; 

Morpliine  Acet.  gr.  i.     M.  S. 
Tablespoonful  every  two  or  three  hours.     If  there  be  much 
heat  of  surface,  we  may  add  to  each  dose  the  eighth,  twelfth 
or  fifteenth  of  a  grain  of  tartar  emetic. 
li'. — Potasste  Carbon.  5i  ; 

Morphiaj  Sul})h.  gr.  i ; 

Saech.  All)i.  5ii ; 

Sue.  Limonis  recent,  r^'n', 

Aquffi  Menth.  v.  Destil.  Siiiss; 

Sp.  ^Ether.  Nitrici.  5ss.     M.  S. 
Tablespoonful  every  hour  or  two. 

The  effervescing  draught,  so  valuable  in  irritability  (»f  the 
stomach,  is  composed  as  follows  : — 
R. — Sue.  Limonis  recent,  sji; 

Sacch.  Albi.  5jiss ; 


Militaru  Surgcr'i/.  77 

Aqnai  Destil.  5ji-     M. 

]jt. — ^Potassffi  Carbon.  5i ; 
Aqnoe  Destil.  5ji-     M. 
Put  two  tablespoonsful  of  the  lemonade  with  one  of  tlie  alka- 
line solution,  and  let  the  mixture  be  drunk  Avhile  effervescing;, 
repeating  the  dose  at  pleasure. 

As  anti2}crio<lics  quinine  and  arsenic  are  tlie  main  reliance 
uf  the  modern  practitioner.  The  former  may  be  given  by 
itself,  in  pill  or  solution,  in  doses  varying  from  two  to  ten 
grains,  according  to  the  urgency  of  the  case  or  the  state  of  the 
system.  My  usual  dose  is  ten  grains  every  eight  ten,  or  twelve 
liours,  until  the  paroxysm  is  arrested.  If  the  symptoms  are 
unusually  violent,  we  need  not  hesitate  to  administer  fifteen 
i^\•  even  twenty  grains  at  a  dose,  being  of  course  careful  to 
watch  the  etfects,  wliich  will  generally  be  more  pleasant  if  a 
little  morphia  be  combined  with  the  quinine. 

In  chronic,  or  frequently-recurring  intermittent  and  neural- 
gic affections,  arsenic  forms  a  valuable,  and,  indeed,  in  many 
cases,  an  indispensable  addition  ;  also  iron,  if  there  be  evi- 
dences of  ana>mia.  I  prefer  myself  the  arsenious  acid  to 
Fowler's  solution,  convinced  that  it  is  much  more  efficacious 
and  at  the  same  time  less  apt  to  cause  nausea  and  anasarca. 
The  following  formula  will  be  found  advantageous : — 

li". — AcidlTArseniosi,  gr.  iss  ; 
Quinire  Sulph. 
Ferri  Sulph.  aa  5i ; 
Morphine  Sulph.  gr.  i ; 
Extr.  Nucis  Vomica?,  I3i. 
M.  ft.  pil.  XXX. 
S.  One  every  live,  six,  or  eight  hours. 

Quinine  is  also  one  of  the  best  tonics^  and  it  nuiy  always  be 
beneficially  combined  with  other  articles,  as  iron,  gentian, 
quassia,  nux  vomica,  and  capsicum.  The  fluid  extracts  and 
aromatic  tinctures  of  bark  and  gentian  will  also  be  found 
useful.  One  of  the  best  chalybeate  preparations  is  the  tinc- 
ture of  the  chloride  of  ii-on,  in  doses  of  from  twenty  to  twenty- 
five  drops  three  or  four  times  daily. 

lixpectorants  constitute  a  large  class  of  remedial  agents,  but 
they  nearly  all  derive  their  active  principles  from  the  admix- 
ture of  tartar  emetic,  ipecacuanha,  or  squills.  They  may 
generally  be  usefully  combined  with  potassa  and  anodynes, 
being  rendered  palatable  by  syrup  or  sugar. 

Nurses  should  be  familiar  with  the  manner  of  administerinc: 
cnemata  or  mjections,  as  frequent  occasions  arise  for  their  em- 


78  Military  Surgery. 

ployment.  They  may  be  cathartic,  aa  when  they  are  designed 
to  empty  tlie  lower  bowel,  or  to  promote  the  action  ot*  other 
remedies;  stimulant,  as  in  case  ot*  excessive  exhaustion;  nu- 
tritive, as  when  food  cannot  be  taken  by  the  mouth  ;  anodyne, 
when  it  is  wislied  to  allay  pain  and  induce  sleep. 

A  cathartic  eiicct;  may  readily  be  inchiced  by  an  injection 
of  a  i)int  and  a  half  of  cold  water,  or  water  in  which  a  little 
ground  mustard  or  common  salt  has  been  stirred,  a  mixture  of 
warm  water  and  castor  oil ;  or  an  infusion  of  senna,  or  senna 
and  Epsom  salts.  Turpentine  is  particularly  indicated  when 
the  bowels  are  distended  with  flatus. 

Stimulating  injections  may  be  made  of  brandy,  alcohol, 
mustard,  salt,  or  spirits  of  camphor  or  turpentine,  mixed  with 
more  or  less  water  ;  and  they  are  often  extremely  serviceable 
in  promoting  reaction. 

yutritive^  Qx\Qm?i.tVi  may  be  necessary  in  the  low  stages  of 
fever,  and  in  gunshot  and  other  injuries  attended  with  lesion 
of  the  gullet.  The  best  ingredients  are  essence  of  beef, 
strong  beef-tea,  brandy,  or  brandy  and  milk,  introduced  in 
smalfquantity  so  as  not  to  o])pre5S  and  irritate  tlie  rectum. 

Anodyne  injections  may  consist  of  laudanum,  black  drt>p, 
morphia,  hyoscyamus,  or  belladonna,  either  alone,  or  various- 
ly combined,  and  administered  with  about  two  ounces  of  tepid 
water,  or  some  demulcent  fluid. 

The  best  syringe  now  in  use  is  the  gutta-percha,  which  is 
not  liable  to  be  deranged,  and  which  has  the  additional  ad- 
vantao-e  of  durability.  It  should  be  «»f  various  capacities, 
from  eight  to  sixteen  ounces,  according  to  the  intention  to  be 
fulfilled"  by  it.  The  nozzle  must  be  well  oiled  previously  to 
its  introduction,  and  care  taken  that  no  air  be  pushed  into  the 
bov/el. 

2. — Topical  liemedies. 

J{'. — Tinct.  lodina^, 

Sp.  Vini  Rectiiic.  aa  5j-     ^1. 
To  be  applied  with  a  large  camel-hair  pencil,   or  cloth,  mop. 
I  hardly  ever  use  the  pure   tincture  ot  iodine  for  local   pur- 
poses. 

]v. — Plumbi  Subacet.  5J  ; 
Pulv.  Opii,5j.     M. 
To  be  put  in  half  a  gallon  of  hot  water,  and  the  solution  to  be 
used  warm  or  cold,  as  may  be  deemed  best.     Laudanum  may 
be  substituted  for  the  opi\im. 

J^. — Pulv.  Ammonia?  llydi-ochlor.  5j  • 
"      Potasste  Nitrat.  5>j  ; 
'•      Opiijoj.     M. 


Military  Surgery.  79 

To  be  used  as  the  preceding  ;  being  particularly  valuable  in 
infianimation  of  the  joints,  on  unbroken  surfaces. 

The  warm  icat-2r-dre8sing  consists  of  warm  water,  simple 
or  medicated  with  laudanum,  acetate  of  lead,  or  any  otlier 
ingredient  that  may  bo  desired,  applied  upon  flannel  or  mus- 
lin cloths,  properly  folded,  and  covered  with  oiled  silk,  to 
confine  heat  and  moisture. 

The  cold  loater-di'cssinfi  is  composed  of  cold  water,  also 
simple  or  msdicated,  applied  with  cloths,  the  parts  being  con- 
stantly exposed  to  the  air  to  promote  evaporation.  The  cloths 
are  to  be  wet  whenever  they  become  heated  or  dryish,  the  water 
being  ])rc?sed  upon  them  from  a  sponge. 

Water-dressings,  if  long  continued,  will  occasionally  cause 
irritation,  itcliing,  and  pustulation  of  the  skin,  rendering  it 
necessary  to  replace  them  with  cataplasms,  or  other  soothing 
remedies. 

Axwow^  2-^oidticis  decidedly  the  best,  for  ordinary  purposes, 
are  the  flaxseed  and  sli;)pery  elm.  The  former  is  made  by 
mixing  a  suitable  quantity  of  linseed  meal  with  hot,  or,  wiiat 
is  stillberter,  boiling  water,  and  rapidly  stirring  it  into  a  thick 
mush-liko  consistence.  The  mixture  is  then  spread  upon  a 
fold  of  cloth,  in  a  layer  a  third  of  an  inch  thick,  when  it  is 
covered  with  bobinet  or  gauze  to  prevent  it  from  adhering  to 
the  parts.  A  piece  of  oiled  silk,  larger  than  the  poultice,  is 
placed  upon  its  outer  surface,  to  retain  heat  and  moisture. 

The  elm,  and,  in  fact,  all  other  cataplasms,  are  prepared 
and  used  upon  the  same  principles  as  the  linseed.  Like  water- 
deessings,  poultices  may  be  simple  or  medicated,  according 
to  the  object  proposed.  They  should  be  changed  at  least 
twice,  or,  in  warm  weather,  even  three  or  four  times  in  the 
twenty-four  hours. 

Adhesive  plaster  is  cut,  in  the  direction  of  its  length,  into 
strips  of  suitable  length  and  breadth^  warmed  by  holding  the 
backs  against  a  smooth  vessel,  as  a  yntcher  or  tin  case,  and 
applied  in  such  a  manner  as  to  bring  the  middle  of  each  piece 
over  the  wound,  the  edges  of  which  are,  meanwhile,  carefully 
supported  by  an  assistant.  A  suitable  space  is  left  between 
the  strips  for  drainage.  If  things  progress  favorably,  substi- 
tution need  not  be  made  under  three  or  four  days.  If  the 
wound  be  large,  only  a  few  of  the  strijjs  are  taken  oft'  at  a 
time,  lest,  all  support  being  lost,  tlie  edges  should  be  forcibl}'^ 
separated. 

Before  the  soiled  dressings  arc  removed,  cverytliing  intend- 
ded  for  the  new  should  be  prepared,. or  put  in  its  proper  place. 
The  strips  of  plaster  must  be  removed  with  great  gentleness. 


80  MUiUiry  Surgery. 

It"  the  injured  parts  are  covered  with  hair,  the  surface  must; 
always  be  shaAcd  before  the  application  of  the  dressings. 

Proper  material  ^oy  sutuns  should  always  be  kept  on  hand, 
ready  for  use.  The  silver  wire  is  the  best,  as  it  is  less  irrita- 
tiiif;  than  any  other.  Silk,  ln>wever,  answers  exceedingly 
well;  the  thread  should  be  rather  thin,  and  be  well  waxed. 
Saddler's  silk  is  the  article  used  for  the  ligation  of  large  ar- 
teries. 

Among  the  more  common  and  usefid  unyuints  for  dressing 
wvninds,  burns,  abraded  surfaces,  or  lissures,  arc  the  follow- 
ing:— 

K-.— I'ulv.  Opii,  5ss  ; 
Pulv.  Tvliei,  »i ; 
Ung.  Cetacei,  oi-     M. 
To  these  ingredients  may  adv.'intageously  be  added,  in   many 
cases  of  healing  sores,  or  eruptions,  requii'ing  a  mild  stimulus, 
a  drachm  of  the  ointment   of  the  nitrate  of  mercury,  a  few 
drops  of  nitric  acid,   two  drachms   of  ointment  of  acetate  of 
lead,  a  small  quantity  of   myrrh,  or  of  balsam  of  Peru,    or 
from  six  to  eight  grains  of  sulphate  of  quinine. 

1^-. — Ung.  Cetacei,  .^i ; 

Bismuth.  Subnitr.  5ij.     M. 
Extremely  soothing  and   valuable  in  superticial  excoriations, 
slight  burns,  and  eczematous  affections.     Turner's  cerate  may 
be  employed  for  similar  purposes,  but  should  always  be  con- 
siderably diluted. 

The  best  disinfectants  are  the  chloride  of  soda,  chloride  of 
lime,  Labarraque's  solution,  and  tlie  hypermanganate  of  po- 
tassa,  of  which  an  abundant  supply  should  always  be  on  haiul 
in  every  hospital,  free  use  of  it  being  made,  by  si)rinkling  and 
otherwise,  upon  the  dressings,  j\s  well  as  upon  the  bedding  and 
the  rooms. 

The  spomjcs  about  a  lios])ital  should  be  of  the  softest  kind, 
})erfectly  clean,  and  always  ready  for  use.  The  same  articles 
nhould  never  be  employed  upon  different  persons,  especially 
where  there  are  foul  or  specitic  sores,  as  contagion  might  thus 
be  communicated  by  direct  inoculation,  as  has,  for  example, 
so  often  happened  during  the  prevalence  of  hospital  gangrene. 

3. — Dietetic  Pre^jarations. 

The  diet  oi  the  sick-room  has  slain  its  thousands  and  tens 
of  thousands.  Broths,  and  slops,  and  jellies,  and  custards, 
and  ptisans  are  usually  as  disgusting  as  they  arc  pernicious. 
Men  worn  out  by  disease  and  injury  must  have  nutritious  and 
concentrated  feod.  The  ordinary  preparafions  for  the  sick  are, 


Military  Surgery.  81 

in  general,  not  only  not  nutritious,  but  insipid  and  flatulent. 
Nitrogenous  food  is  Avhat  is  needed,  even  if  the  quantity  taken 
be  very  small.  Animal  soups  are  among  the  most  efficient 
supporters  of  the  exhausted  system,  and  evory  medical  man 
should  know  how  to  give  directions  for  their  preparation.  The 
life  of  a  man  is  his  food.  Solid  articles  are  of  course  with- 
held in  acute  diseases,  in  their  earlier  stages,  but  when  the 
patient  begins  to  convalesce  they  are  frequently  borne  with 
impunity,  and  greatly  promote  recovery.  All  animal  soups 
should  be  made  of  lean  meat ;  and  their  nutritious  properties, 
as  well  as  their  flavor,  may  be  much  increased  by  the  addi- 
tion of  some  vegetable  substance,  as  rice  or  barley.  If  the 
stomach  is  very  weak,  they  may  be  diluted,  or  seasoned  with 
pepper. 

Essence  of  heef,  so  frequently  given  in  the  low  stages  of 
fever,  and  in  the  exhaustion  consequent  Tipon  severe  injuries 
and  operations,  is  prepared  by  cutting  from  a  quarter  to  half 
a  pound  of  lean  beef  into  thin  pieces,  and  putting  it  into  a 
wide-mouthed  porter  bottle,  corked  tightly,  and  placed  in  a 
kettle  of  cold  water,  which  is  then  heated  till  it  boils.  After 
it  has  been  digested  in  this  way  for  a  few  hours,  the  juice  is 
decanted,  and  seasoned  with  salt  and  pepper,  wine  or  brandy. 

Beef  tea,  much  less  nourishing  than  beef  essence,  is  made 
by  putting  a  quarter  of  a  pound  of  lean  l)eef  in  a  pint  and  a 
half  of  water,  and  boiling  it  for  flfteen  minutes,  a  lev.'  blades 
of  mace  being  added  during  the  process,  and  the  fluid  well 
skimmed. 

To  make  cJiickeii  hroth  requires  half  a  young  chicken  and  a 
quart  of  cold  water,  with  a  teaspoonful  of  rice  or  barley,  the 
whole  being  slowly  boiled  for  tAvo  hours  under  cover,  with 
proper  skimming. 

Chiclcen  jelly  is  prepared  by  putting  a  chicken,  cut  up  and 
all  the  bones  broken,  in  a  stone  jur,  closely  covered,  and  re- 
tained in  boiling  water  for  three  hours  and  a  half.  The  liqr.or 
is  then  strained,  and  seasoned  with  salt  and  mace. 

Vegetahle  soup  is  composed  of  two  Irish  potatoes,  one  onion, 
and  a  piece  of  bread,  with  a  quart  of  water,  boiled  down  to 
a  pint  in  a  closely-covered  vessel,  a  little  celery  or  parsley 
being  introduced  near  the  close  of  tlie  operation.  Salt  and 
pepper  are  added  at  pleasure. 

To  form  ynce  jelly  a  quarter  of  a  pound  of  rice  flour  aiul 
twice  that  quantity  of  loaf  sugar  are  boiled  in  a  quart  of 
Avater,  until  the  whole  becomes  a  glutinous  mass,  Avhen  the 
jelly  is  strained  oft'  and  flavored. 

Sayo  jelly  is  composed  of  four  tiiblespoouful  of  sago,  one 


82  MiUiccry  Sutgery. 

quart  of  water,  juice  andiind  of  one  Icniou.  audeuougii  sugar 
to  render  it  .agreeable.  After  the  mixture  has  stood  half  ati 
Lour,  it  ih  boiled  until  all  the  particles  are  entirely  dissolved, 
the  nias9  being  constantly  stirred. 

Oatmeal  gi'uel  is  conijiosed  of  two  large  h-poonsful  of  oat- 
meal and  half  a  ])int  of  milk,  stirred  into  one  pint  of  boiling 
water,  and  allowed  to  simmer  for  thirty  minutes,  when  it  is 
strained  through  a  hair  sieve.  CorvmeaJ  gruel  is  i»rej)ared  in 
a  similar  manner. 

Arrov>root  pap  consists  of  a  large  tablespoonfnl  of  this 
substance  made  into  a  paste  with  a  liiile  cold  water,  which  is 
then  stirred  into  a  ]>int  of  boiling  water,  and  kept  on  the  tire 
for  five  minutes.  The  nourishing  properties  ot  arrow  root 
pap  may  be  heightened  l)y  using  milk  instead  of  water  in  its 
preparation. 

Milk  toast  is  often  much  relished  by  the  sick ;  and  there  is 
a  very  excellent  jelly  for  invalids  made  of  a  thinly  sliced  and 
slightly  toasted  ])enny  roll,  boiled  in  a  quart  of  water  until  it 
becomes  a  glutinous  mass,  when  it  should  be  stj-ained  upon  a 
few  shavings  of  lemon-peel. 

The  flavor  and  cflicacy  of  the  various  dietetic  prcjxij-ations 
here  described  may  be  greatly  increased  by  the  addition  of 
mace,  lemon,  wine,  or  brandy.  When  salt,  or  salt  and  pepper 
are  used,  the  patient's  own  taste  should  be  consulted.  Great 
care  should  be  employed  in  making  these  compounds  that  they 
are  not  scorched.  To  prevent  this  a  double  l)oiler  should  be 
used. 

Milk-punchy  an  excellent  article  v\-hen  a  stimulant  is  re- 
quired m  conjunction  with  a  nutrient,  is  made  by  mixinggood 
brandy  with  cold,  fresh  milk,  in  the  jiroportion  of  about  one 
ounce  of  the  foruicr  to  half  a  pint  of  the  latter.  Sugar  and 
nutmeg  may  be  added  to  make  the  mixture  palatable. 

Wine-v)}iey^  well  made,    may  be  rendered  of  great  service 
to  the  sick.     It  is  ])repared  by  adding  to  a  pint  of  fresh  milk, 
as  soon  as  it  reaches  the  Itoiling  ])oint,  as  n)uch  good  Madeira 
or  Sherrv  as  will  coatjulate  it.     The  mixture  is  then  strained 
and  sweetened  or  flavored  tor  use. 

The  best  wines  for  the  sick  are  Madeira,  port,  and  sherry. 
In  cases  of  gastric  irritation,  champagne  sometimes  produces 
an  excellent  effect,  quieting  the  stomach  as  well  as  the  system 
at  hirgc. 

Jigg-nog  consists  of  an  ii^^^  the  white  and  yolk  of  which 
are  beaten  up  separately;  half  a  pint  of  cold  water  with  a 
little  loaf-sugar  is  then  added,  together  with  two  tablespoons- 
ful  of  brandy. 


Ik 


i 


